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 D. Limiting the number of choices for the client who has Alzheimer's disease can help reduce confusion and frustration and promote independence and dignity. Using written signs to assist the client with locating the bathroom may not be helpful, as the client may have difficulty reading or remembering what they mean. Using confrontation to manage the client's behavior can increase agitation and aggression and worsen cognitive decline. Providing a stimulating environment for the client can also overwhelm and overstimulate them and cause sensory overload.
Correct Answer is B
Explanation
Choice A reason
While thinning of secretions can be a positive sign, it's not always visible. A decrease in peak inspiratory pressure is a more objective indicator of improved airway patency.
Choice B reason.
Peak inspiratory pressure is the maximum pressure required to push air into the lungs. If suctioning is effective, it will remove secretions and reduce airway resistance, leading to a decrease in peak inspiratory pressure
Choice C reason:
While a productive cough can indicate that secretions are being moved, it doesn't directly measure the effectiveness of suctioning.
Choice D reason:
Flattening of the artificial airway cuff: Flattening of the artificial airway cuff is not a relevant indicator of the effectiveness of suctioning. The cuff of an endotracheal tube is inflated to prevent air leaks around the tube and to maintain proper ventilation. It is not directly related to the effectiveness of suctioning.
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