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 A
Explanation
Rationale:
A. "Schedule rest periods during the day.": Fatigue is a common symptom of multiple sclerosis. Scheduling rest periods helps conserve energy, prevent exacerbation of symptoms, and improve overall functioning without overtaxing the client.
B. "Soak in a hot bath.": Heat can worsen multiple sclerosis symptoms by temporarily increasing nerve conduction delays. Hot baths may trigger fatigue or weakness and are generally discouraged.
C. "Perform aerobic activities three times per week.": While gentle exercise is beneficial, intense aerobic activity can exacerbate fatigue and heat sensitivity in clients with multiple sclerosis. Exercise should be balanced with rest periods.
D. "Have your partner complete activities of daily living for you.": Encouraging total dependence can reduce independence and self-efficacy. Clients should perform activities within their capacity to maintain function while pacing themselves appropriately.
Correct Answer is ["8"]
Explanation
Calculation:
- Identify the prescribed dose and the available concentration.
Prescribed dose = 40 mg
Available concentration = 5 mg per 1 mL
- Calculate the volume in milliliters (mL) to administer.
Volume (mL) = (Prescribed dose (mg) / Available concentration (mg/mL))
= (40 mg / 5 mg/mL)
= 8 mL.
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