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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. "You might feel a bit confused for a few hours after the procedure": Confusion is a common side effect of electroconvulsive therapy (ECT) immediately following the procedure. It typically resolves within a few hours as the effects of anesthesia wear off. Providing this information prepares the client for potential post-procedure effects.
B. "You might notice some changes in your voice after the procedure": Changes in voice are not typically associated with ECT. Therefore, this statement is not relevant to the client's education about what to expect during or after the procedure.
C. "You'll wake up about 30 minutes after the procedure": The duration of unconsciousness following ECT can vary from person to person. While clients typically awaken within minutes after the procedure, specifying a time frame of 30 minutes may not accurately reflect individual experiences.
D. "You can expect to feel some pulsations in your neck during the procedure": Feeling pulsations in the neck is not a common sensation experienced during ECT. This statement does not accurately describe the procedure or its associated sensations.

A. "Did anything in particular make you feel this way?" B. "Do you ever think about harming yourself?" C. "How long have you had these feelings of uselessness?" D. "Would you tell me more about the changes you see in your body?"

Correct Answer is B

Explanation

A. "Did anything in particular make you feel this way?" - While exploring potential triggers for the client's feelings of uselessness is important, assessing for suicidal ideation takes precedence. However, this question can be asked after addressing the immediate safety concern.
B. "Do you ever think about harming yourself?" - This is the priority assessment question. Older adults experiencing feelings of uselessness and worthlessness may be at risk for suicidal ideation or self-harm. Asking about thoughts of self-harm allows the nurse to assess the client's safety and determine the need for immediate intervention.
C. "How long have you had these feelings of uselessness?" - While understanding the duration of the client's feelings is relevant, assessing for suicidal ideation is more critical in ensuring the client's safety.
D. "Would you tell me more about the changes you see in your body?" - Exploring the client's perception of physical changes is important for addressing body image concerns and promoting self-esteem. However, assessing for suicidal ideation takes precedence as it addresses the client's immediate safety.

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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?

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