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 ["A","C"]

Explanation

Varicella zoster is highly contagious, and airborne precautions should be implemented. Assigning the client to a negative pressure airflow room helps prevent the spread of the virus to others by containing and filtering the air within the room.

In addition to airborne precautions, contact precautions should also be implemented. This includes using gloves and gowns when providing care to the client to minimize direct contact with infectious materials.

The other options listed are not appropriate interventions for a client with varicella zoster: While it is important to minimize close contact with an infectious client, varicella zoster is

primarily transmitted through airborne droplets. Visitors should follow the appropriate precautions, such as wearing masks and adhering to hand hygiene, rather than just maintaining a certain distance.

Aspirin should not be given to clients with varicella zoster, especially children, due to the risk of developing Reye's syndrome. Reye's syndrome is a rare but serious condition that can cause swelling in the liver and brain. Acetaminophen (paracetamol) is typically recommended for managing fever in clients with varicella zoster.

A. Tinnitus B. Constipation C. Joint pain D. Blurry vision

Correct Answer is D

Explanation

Answer: D. Blurry vision

Rationale: Blurry vision, along with yellow-green halos around lights, is a sign of digoxin toxicity that can occur when the serum level of the drug exceeds 2 ng/mL. Other signs of digoxin toxicity include nausea, vomiting, anorexia, confusion, arrhythmias, and bradycardia. Tinnitus, constipation, and joint pain are not related to digoxin toxicity.

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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 is assisting with the admission of a client who has varicella zoster. Which of the following interventions should the nurse plan to implement?

Correct Answer is ["A","C"]

Explanation

A nurse is reinforcing teaching with a client who is starting digoxin therapy to treat heart failure. The nurse should reinforce with the client that which of the following adverse effects is a possible indication of digoxin toxicity and should be reported to the provider?

Correct Answer is D

Explanation

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