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 D
Explanation
The correct answer is choice D. Document the client’s condition after every 15 minutes.
Choice A rationale:
Requesting a PRN restraint prescription for clients who are aggressive is not appropriate because restraints should only be used as a last resort and not on a PRN basis. Restraints should be used only when necessary to ensure the safety of the patient and others, and always with a specific, time-limited order.
Choice B rationale:
Removing the client’s restraint every 4 hours is not frequent enough. Restraints should be removed more frequently to assess the patient’s condition, provide care, and ensure that the restraint is still necessary.
Choice C rationale:
Attaching the restraint to the bed’s side rails is unsafe. Restraints should be attached to a part of the bed frame that moves with the patient to prevent injury.
Choice D rationale:
Documenting the client’s condition every 15 minutes is the correct guideline. Frequent documentation ensures that the patient’s condition is continuously monitored, and any changes can be addressed promptly to ensure safety and well-being.
Correct Answer is A
Explanation
Choice A reason:
Among the options listed, cheese is the food that is contraindicated with MAOI use. Cheese is high in tyramine, and consuming it while taking MAOIs can lead to a potentially life-threatening hypertensive crisis.
An MAOI (Monoamine Oxidase Inhibitor) is a type of medication used to treat depression, anxiety, and other psychiatric disorders. When taking MAOIs, it is important to avoid certain foods that contain high levels of tyramine, as it can lead to a dangerous increase in blood pressure known as a hypertensive crisis.
Choice B reason:
Potatoes: Potatoes are not contraindicated with MAOI use. They do not contain significant levels of tyramine.
Choice C reason:
Grapefruit: Grapefruit is not contraindicated with MAOI use. However, it can interact with certain medications, so it's always a good idea to check with the healthcare provider or pharmacist about specific medication interactions.
Choice D reason:
D. Eggs: Eggs are not contraindicated with MAOI use. Like potatoes, they do not contain significant levels of tyramine.
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