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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Rationale:
A. Provide a pacifier for nonnutritive sucking: Offering a pacifier promotes nonnutritive sucking, which supports oral motor development and provides comfort for the infant during gastrostomy tube feedings. This practice can help the infant transition more easily to oral feeding later.

B. Warm the formula in the microwave prior to administration: Warming formula in the microwave is unsafe because it can create hot spots that may burn the infant’s mouth or esophagus. Formula should be warmed using a bottle warmer or by placing the container in warm water.

C. Change the gastrostomy tube every 3 days: Routine gastrostomy tube replacement every 3 days is unnecessary and can cause trauma. Tubes are generally changed according to manufacturer recommendations or when malfunction or blockage occurs.

D. Place the infant in a supine position after the feeding: Infants should be kept in an upright or semi-upright position during and after feedings to reduce the risk of aspiration. Supine positioning increases the likelihood of reflux and respiratory complications.

A. Perform range-of-motion exercises once per shift. B. Place the client in high-Fowler's position. C. Implement seizure precautions. D. Monitor the client for hypoglycemia.

Correct Answer is C

Explanation

Rationale:
A. Perform range-of-motion exercises once per shift: While ROM exercises help maintain joint mobility, they are not a priority in the acute management of bacterial meningitis. The immediate focus is on preventing complications such as seizures and managing neurological status.

B. Place the client in high-Fowler's position: Although elevated head positioning can reduce intracranial pressure slightly, there is no strict requirement for high-Fowler’s positioning in bacterial meningitis. Comfort and safety are more important, with frequent neurological monitoring.

C. Implement seizure precautions: Bacterial meningitis increases the risk of seizures due to inflammation and increased intracranial pressure. Implementing seizure precautions—such as padding side rails, having suction available, and ensuring rapid access to emergency equipment—is a key safety measure.

D. Monitor the client for hypoglycemia: Hypoglycemia is not typically a complication of bacterial meningitis. Instead, monitoring focuses on neurological status, vital signs, fluid balance, and signs of increased intracranial pressure.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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