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 A
Explanation
Choice A rationale:
Consuming foods high in bran fiber can help regulate bowel movements and alleviate symptoms of irritable bowel syndrome (IBS). Fiber adds bulk to the stool and can prevent constipation, a common symptom in IBS patients. Adequate dietary fiber intake is generally recommended for individuals with IBS.
Choice B rationale:
Increasing intake of foods high in gluten might worsen symptoms in individuals with gluten sensitivity or celiac disease. Gluten-containing foods can trigger gastrointestinal distress in susceptible individuals and should be avoided if gluten intolerance is present.
Choice C rationale:
Some individuals with IBS are lactose intolerant, which means they have difficulty digesting milk products. Increasing intake of milk products can exacerbate symptoms such as bloating, gas, and diarrhea in these individuals. It is important to assess the client's tolerance to lactose-containing foods before recommending their consumption.
Choice D rationale:
Sweetening foods with fructose corn syrup may worsen symptoms in individuals with IBS. Fructose is a type of sugar that can cause gastrointestinal distress in some people, especially those with fructose malabsorption. Recommending sweeteners with low fructose content would be more appropriate for individuals with IBS.
Correct Answer is D
Explanation
Choice A rationale:
Managing conflict within the group is an important skill, but it is more appropriate for the working phase of group therapy. During the orientation phase, the focus is on establishing trust, setting group norms, and creating a safe environment. Conflict resolution skills become more relevant as the group progresses.
Choice B rationale:
Encouraging the use of problem-solving skills is essential in group therapy, but it is a skill that is developed during the working phase. During the orientation phase, the nurse focuses on building rapport, creating a comfortable atmosphere, and explaining the purpose and goals of the group.
Choice C rationale:
Maintaining the group's focus on identified issues is a crucial aspect of the orientation phase. The nurse should guide the discussion to ensure that participants understand the purpose of the group and stay on topic. This helps in establishing clear goals and expectations for the group sessions.
Choice D rationale:
Establishing a rapport with group members is a primary goal of the orientation phase. Building trust and a therapeutic relationship with the adolescents creates a supportive environment where they feel comfortable sharing their experiences and emotions. A strong rapport enhances the effectiveness of the support group.
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.