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 C
Explanation
A. The nurse wears an N95 respirator when performing client care: Measles is highly contagious and spreads through respiratory droplets. Wearing an N95 respirator provides appropriate respiratory protection for the nurse when caring for a client with measles. This action is appropriate and does not require intervention by the charge nurse.
B. The nurse places the client on airborne precautions: Measles is transmitted via airborne droplets, so placing the client on airborne precautions is necessary to prevent the spread of the disease to others. This action is appropriate and aligns with infection control guidelines.
C. The nurse ensures the client's room maintains a positive airflow: Positive airflow can potentially contribute to the spread of airborne pathogens outside the room, increasing the risk of transmission to others. For clients with airborne infections like measles, negative airflow rooms are required to minimize the risk of transmission to healthcare workers and other clients. Therefore, the charge nurse should intervene and correct this action.
D. The nurse has the client wear a mask for transport to radiology: Having the client wear a mask during transport helps minimize the spread of infectious droplets to others in the facility. This action is appropriate and aligns with infection control measures for airborne precautions
Correct Answer is B
Explanation
A. Atropine: Atropine is not used to treat benzodiazepine toxicity. It is primarily indicated for treating bradycardia, organophosphate poisoning, and certain types of poisoning causing excessive muscarinic effects.
B. Flumazenil: Flumazenil is a benzodiazepine receptor antagonist and is used to reverse the sedative effects of benzodiazepine overdose or toxicity. It competitively inhibits the action of benzodiazepines at the receptor site, reversing their effects.
C. Naloxone: Naloxone is a medication used to reverse opioid overdose by competitively binding to opioid receptors and displacing opioid agonists. It is not effective in treating benzodiazepine toxicity.
D. Activated charcoal: Activated charcoal is used to absorb ingested toxins in cases of poisoning. However, it is not effective in treating benzodiazepine toxicity because benzodiazepines are not effectively absorbed by activated charcoal.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.