A nurse in an acute care mental health facility is placing a client in seclusion and restraints.
Which of the following actions should the nurse plan to take?
Request a provider to evaluate the client in person every 36 hr.
Document the client's behavior every 15 min.
Ensure that the prescription for restraints be renewed every 6 hr.
Plan to monitor the client every 30 min while restrained.
The Correct Answer is B
Choice A rationale:
Requesting a provider to evaluate the client in person every 36 hours might be necessary in certain situations but is not directly related to the management of a client in seclusion and restraints. It does not ensure the immediate safety and well-being of the client in this scenario.
Choice B rationale:
Documenting the client's behavior every 15 minutes is essential when a client is in seclusion and restraints. Regular and detailed documentation is crucial to monitor the client's response to the intervention, ensuring their safety, and providing necessary information for the healthcare team.
Choice C rationale:
Ensuring that the prescription for restraints be renewed every 6 hours is important to prevent unnecessary or prolonged use of restraints, but it doesn't address the immediate need for monitoring the client in seclusion and restraints.
Choice D rationale:
Monitoring the client every 30 minutes while restrained might not provide timely information, especially if the client's condition deteriorates rapidly. More frequent monitoring, such as every 15 minutes, allows for closer observation and quicker response to any changes in the client's status.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Expressing concern about another shift's holiday hours does not necessarily involve interpersonal conflict. It may reflect dissatisfaction but doesn't involve direct conflict between individuals.
Choice B rationale:
A personal difficulty with caring for clients who have HIV could be a challenge for the nurse, but it's not an example of interpersonal conflict. It represents a personal struggle rather than a conflict with another individual.
Choice C rationale:
Insulting comments directed at a nurse by another nurse represent interpersonal conflict. Such behavior involves a direct clash of personalities and can create a hostile work environment, affecting the nurse's well-being and job performance. Addressing this type of conflict is crucial for maintaining a positive work atmosphere.
Choice D rationale:
Submitting a complaint about another department's handoff reporting might indicate dissatisfaction or concerns about workflow, but it's not necessarily an interpersonal conflict. It could be a communication issue or a difference in professional opinion rather than a direct clash between individuals.
Correct Answer is D
Explanation
Choice A rationale:
Metallic taste in mouth. Metallic taste in the mouth is a common side effect of many medications, including sertraline. It occurs due to the medication's effect on taste receptors. Patients should be informed about this side effect, but it is not a serious adverse effect that requires immediate medical attention.
Choice B rationale:
Increased urinary frequency. Increased urinary frequency is not a commonly reported side effect of sertraline. While some individuals may experience changes in urination patterns, it is not a significant adverse effect associated with this medication.
Choice C rationale:
Dry cough. Dry cough is not a known side effect of sertraline. Cough can occur due to various reasons, such as allergies, respiratory infections, or other medications, but it is not directly caused by sertraline.
Choice D rationale:
Excessive sweating. Excessive sweating, also known as hyperhidrosis, is a potential adverse effect of sertraline. It can be bothersome for some individuals and may impact their quality of life. Patients should be aware of this side effect and report it to their healthcare provider if it becomes bothersome or persistent.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.