A nurse is assessing a client who is in mechanical restraints after Hitting a staff member. Which of the following findings indicates that the nurse should discontinue the restraints?
The client reports that the restraints are too tight.
The client has been in the restraints for 4hr.
The client is able to calmly follow commands.
The client can explain the reasons for their behavior.
The Correct Answer is C
A. The client reports that the restraints are too tight: This indicates a need for adjustment of the restraints but does not necessarily indicate that the restraints should be discontinued altogether. The client's ability to follow commands and behave safely is a more critical factor in deciding whether to discontinue the restraints.
B. The client has been in the restraints for 4 hours: While prolonged use of restraints should be avoided due to the risk of complications such as skin breakdown and loss of mobility, the duration alone may not be the sole indicator for discontinuing restraints. The client's behavior and ability to follow commands are more important considerations.
C. The client is able to calmly follow commands: This is the most appropriate finding indicating that the restraints should be discontinued. Calmly following commands suggests that the client's behavior has improved and they are no longer a danger to themselves or others, making the restraints unnecessary.
D. The client can explain the reasons for their behavior: While understanding the reasons for the client's behavior is important for addressing underlying issues, it does not necessarily indicate that the client is no longer a risk to themselves or others. The ability to calmly follow commands is a more immediate concern when deciding whether to discontinue restraints.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["2250"]
Explanation
To calculate the total volume of IV fluid intake for the client, we need to add up the volumes of each type of fluid administered.
For 0.45% sodium chloride IV at 500 mL/hr for 3 hr:
Volume = Rate × Time = 500 mL/hr × 3 hr = 1500 mL
For 0.45% sodium chloride IV at 200 mL/hr for 3 hr:
Volume = Rate × Time = 200 mL/hr × 3 hr = 600 mL
For dextrose 5% in water at 75 mL/hr for 2 hr:
Volume = Rate × Time = 75 mL/hr × 2 hr = 150 mL
Total volume = 1500 mL + 600 mL + 150 mL = 2250 mL
Therefore, the nurse should document a total volume of 2250 mL for the client's IV fluid intake.
Correct Answer is C
Explanation
A. The client reports that the restraints are too tight: This indicates a need for adjustment of the restraints but does not necessarily indicate that the restraints should be discontinued altogether. The client's ability to follow commands and behave safely is a more critical factor in deciding whether to discontinue the restraints.
B. The client has been in the restraints for 4 hours: While prolonged use of restraints should be avoided due to the risk of complications such as skin breakdown and loss of mobility, the duration alone may not be the sole indicator for discontinuing restraints. The client's behavior and ability to follow commands are more important considerations.
C. The client is able to calmly follow commands: This is the most appropriate finding indicating that the restraints should be discontinued. Calmly following commands suggests that the client's behavior has improved and they are no longer a danger to themselves or others, making the restraints unnecessary.
D. The client can explain the reasons for their behavior: While understanding the reasons for the client's behavior is important for addressing underlying issues, it does not necessarily indicate that the client is no longer a risk to themselves or others. The ability to calmly follow commands is a more immediate concern when deciding whether to discontinue restraints.
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