A nurse in an acute mental-health facility is caring for an adolescent who is exhibiting destructive behavior. Which of the following actions should the nurse take after applying physical restraints to the client?
Monitor the client's range of motion every 60 min.
Offer the client a nutritious snack every 4 hr.
Plan to remove the restraints as soon as the client is calm
Ensure that the provider has signed a prescription for restraints within 48 hr.
The Correct Answer is C
The correct answer is C. Plan to remove the restraints as soon as the client is calm. Physical restraints should be used as a last resort and for the shortest duration possible to ensure
client safety. The nurse should assess the client frequently and remove the restraints when they are no longer needed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A option:
Dietitian should not be consulted: The dietitian is an essential team member and will work closely with the client to ensure proper nutrition and dietary management. However, in the context of dysphagia, the speech-language pathologist's expertise is needed to determine safe swallowing strategies and food modifications.
Choice B option:
Physical therapist should not be consulted: The physical therapist focuses on maintaining and improving the client's physical function and mobility. While important in ALS management, the physical therapist's role is not directly related to the immediate issue of dysphagia.
Choice C option:
The speech-language pathologist is the correct answer because it specializes in assessing and treating communication and swallowing disorders. In this case, the speech-language pathologist is essential in evaluating the client's swallowing function, recommending appropriate dietary modifications (texture and consistency of foods), and implementing swallowing exercises or strategies to improve swallowing safety.
Choice D option:
Occupational therapist should not be consulted: The occupational therapist assists clients in regaining or maintaining independence in daily living activities. While the occupational therapist may address some aspects of mealtime activities and adaptive strategies, the speech-language pathologist is more specialized in evaluating and treating swallowing difficulties in clients with ALS.
Correct Answer is B
Explanation
The correct answer is choiceb. Place the client in Trendelenburg position.
Choice A rationale:
Loosely wrapping the cord with petroleum gauze is not recommended.Instead, the cord should be wrapped with sterile saline-soaked gauze to prevent it from drying out and to minimize infection risk.
Choice B rationale:
Placing the client in Trendelenburg position helps to relieve pressure on the prolapsed cord by using gravity to shift the fetus away from the pelvis. This position helps to improve blood flow through the umbilical cord until delivery can be arranged.
Choice C rationale:
Evaluating uterine tone is not directly related to managing a prolapsed umbilical cord.The priority is to relieve pressure on the cord to prevent fetal hypoxia.
Choice D rationale:
Applying fundal pressure is contraindicated as it can increase pressure on the prolapsed cord, worsening the situation.
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