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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale:

Amputation, although a significant medical history, is not a contraindication to becoming a living kidney donor. The presence of an amputation does not directly impact the person's ability to donate a kidney to their parent.

Choice B rationale:

Primary glaucoma, a condition affecting the eyes, is also not a contraindication to kidney donation. While eye conditions can affect overall health, they do not specifically prevent an individual from donating a kidney if they are otherwise healthy.

Choice C rationale:

Hypertension (high blood pressure) is a contraindication to kidney donation. Individuals with hypertension are at a higher risk of developing kidney disease themselves. Additionally, donating a kidney could exacerbate their condition, potentially leading to further complications. Therefore, this is the correct choice.

Choice D rationale:

Osteoarthritis, a condition affecting the joints, is not a contraindication to kidney donation. Joint problems do not directly impact kidney function or the ability to donate a kidney.

A. Decreased BUN level B. Decreased hemoglobin level C. Increased urinary output D. Increased weight of 0.91 kg (2 lb)

Correct Answer is C

Explanation

The correct answer is C. Increased urinary output indicates that furosemide, a loop diuretic, is effective in reducing fluid retention and edema in clients with heart failure. The other findings are not indicative of furosemide effectiveness and may suggest adverse effects or complications. Decreased BUN level may indicate overhydration or liver dysfunction. Decreased hemoglobin level may indicate anemia or bleeding. Increased weight of 0.91 kg (2 lb) may indicate fluid overload or worsening heart failure.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has end-stage kidney disease.The client's adult child asks the nurse about becoming a living kidney donor for their parent.Which of the following conditions in the child's medical history should the nurse identify as a contraindication to the procedure?

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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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?