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 C
Explanation
Rationale:
A. Transfer on the client's weaker side when moving a client from a bed to a chair: Clients should be moved toward their stronger side to facilitate participation and reduce strain on both the client and the nurse. Transferring toward the weaker side increases risk of injury and reduces stability.
B. Raise the head of the bed when transferring a client from a bed to a stretcher: Raising the head of the bed does not directly enhance safe body mechanics or ergonomic principles during a transfer. Proper lifting techniques and devices are more critical for preventing injury.
C. Use a lateral transfer device when moving a client from a bed to a stretcher: Using a lateral transfer device, such as a sliding board or transfer sheet, minimizes manual lifting, reduces musculoskeletal strain, and follows ergonomic principles. It is a key safety strategy for both the client and healthcare staff.
D. Use a pillow underneath the client's head when repositioning a client in bed: Placing a pillow under the head supports comfort and alignment but does not relate to ergonomic principles or safe lifting techniques. Ergonomics focuses on body mechanics, positioning, and injury prevention for caregivers.
Correct Answer is C
Explanation
Rationale:
A. "Remove a plug from the socket by pulling the cord.": Pulling a plug out by the cord can damage the wiring and expose live electrical components, increasing the risk of electric shock or fire. The plug should always be removed by grasping the base of the plug itself to ensure safety.
B. "Check for a tingling sensation around the cord.": A tingling sensation indicates faulty wiring or electrical leakage, which poses a serious safety hazard. Rather than checking for it, individuals should immediately stop using any cord that gives off a tingling sensation and report or replace it.
C. "Use three-pronged grounded plugs.": Grounded plugs provide an essential safety feature by redirecting excess electrical current safely into the ground. This reduces the risk of electrical fires and shocks, especially in appliances with metal casings or high power consumption.
D. "Cover extension cords with a rug.": Covering cords traps heat, prevents adequate ventilation, and increases the risk of overheating and fire. Extension cords should remain uncovered and placed in areas where they will not be walked on or damaged.
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