A nurse is assessing a client who was placed in restraints for aggressive behavior. The client is now calm and cooperative. Which of the following actions should the nurse take?
Remove the restraints from the client.
Offer the client PRN pain medication.
Continue to monitor the client every 15 min.
Encourage the client to attend a group therapy session.
The Correct Answer is A
Rationale:
A. Remove the restraints from the client: Restraints should be discontinued as soon as the client no longer poses a danger to themselves or others. Prompt removal prevents unnecessary restriction and respects the client’s rights and dignity.
B. Offer the client PRN pain medication: While assessing for discomfort is important, pain medication is not the immediate priority once the client is calm and cooperative, unless the client requests it or shows signs of pain.
C. Continue to monitor the client every 15 min: Monitoring should continue after restraint removal according to facility policy, but the first action is to remove the restraints to avoid unnecessary confinement.
D. Encourage the client to attend a group therapy session: While therapeutic activities are important, this is not the immediate action following restraint use. Ensuring the client’s safety and removing restraints takes priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Stagger care to avoid taking more than one specimen at a time: While staggering procedures can reduce cumulative stress, it is not a primary strategy for obtaining cooperation from a preschooler for a single blood draw.
B. Apply vapocoolant spray immediately prior to collecting the specimen: Vapocoolant sprays can help numb the skin, but their use in preschoolers requires caution, as sudden cold sensations may startle or frighten the child. Additional preparation and explanation are necessary for acceptance.
C. Ask the parents to leave the room prior to collecting the blood specimen: Preschoolers often feel more secure and cooperative when a parent is present. Removing the parent may increase anxiety and resistance to the procedure, so parental support is usually encouraged.
D. Demonstrate the use of the equipment for the child: Preschoolers benefit from simple, age-appropriate explanations and demonstrations of medical equipment. Showing how the equipment works helps reduce fear, build trust, and increase cooperation during the blood draw.
Correct Answer is C
Explanation
Rationale:
A. A client who reports frequent and painful urination: This client likely has a urinary tract infection, which requires assessment and treatment but is not immediately life-threatening.
B. A client who reports left arm pain following a fall: Pain from trauma requires evaluation, but unless there are signs of impaired circulation or severe injury, it is lower priority than potential neurologic emergencies.
C. A client who has hypertension and reports a severe headache: A severe headache in a client with hypertension may indicate a hypertensive crisis or impending stroke. Immediate assessment is required to prevent life-threatening complications, making this the highest priority.
D. A client who has heart failure and received a diuretic 30 min ago: Monitoring is necessary to assess diuretic effects, but this client is stable and does not require immediate intervention compared with the client at risk for hypertensive emergency.
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