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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

The correct answer is B. The nurse should encourage the family to express their feelings of loss and provide emotional support and comfort during this difficult time. The nurse should also respect their cultural and religious beliefs and practices regarding death and dying, and allow them to spend as much time as they need with their loved one's body, unless there are infection control issues or legal requirements that prevent it. The other options are incorrect because they are insensitive and disrespectful to the family's needs and wishes.

A. Face B. Shoulders C. Palm of the hands D. Sclera

Correct Answer is D

Explanation

Choice A reason:

The face is incorrect: Facial skin colour can vary for many reasons, but it may not be the best indicator of jaundice in individuals with dark skin.

Choice B reason

Shoulders is incorrect: The shoulders are not typically indicative of jaundice.

Choice C reason:

Palm of the hands is incorrect: While the palm of the hands can sometimes show yellowing in cases of jaundice, it is less reliable than observing the sclera.

Choice D reason:

Sclera is the best location. In individuals with darker skin tones, yellowish discoloration of the skin due to jaundice can be more challenging to detect. However, the sclera of the eyes can still show noticeable yellowing, making it a reliable location for assessing jaundice in individuals with both light and dark skin.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse caring for the family of a client who recently died. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is performing a skin assessment on a client who has a dark skin. Which one of the following locations on the client’s body should the nurse observe to access for jaundice?

Correct Answer is D

Explanation

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