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 immediately.

Encourage the client to attend a group therapy session.

Continue to monitor the client every 15 minutes.

Administer a sedative to maintain calm behavior.

Answer and Explanation

The Correct Answer is C

Choice A reason: Removing restraints immediately risks safety, as the client’s calm state may not be sustained. Restraints require gradual removal after ensuring sustained behavioral stability, per facility policy and safety standards. Frequent monitoring is needed to assess ongoing safety, making this action premature and potentially unsafe.
Choice B reason: Encouraging group therapy is inappropriate while the client remains in restraints, as it does not address the immediate need to evaluate their behavior for safe restraint removal. Therapy may be beneficial later, but ongoing monitoring is the priority to ensure safety and compliance with restraint protocols.
Choice C reason: Continuing to monitor the client every 15 minutes ensures safety while assessing sustained calm and cooperative behavior. This adheres to restraint protocols, which require frequent checks to evaluate the need for continued restraint, prevent complications, and plan for safe removal, making it the correct action.
Choice D reason: Administering a sedative to maintain calm behavior is inappropriate without a current medical order or ongoing aggression. Sedatives carry risks like oversedation or respiratory depression. Monitoring the client’s behavior is the priority to determine if restraints can be safely discontinued, making this action unnecessary and potentially harmful.

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Correct Answer is A

Explanation

Choice A reason: A BMI of 32 indicates obesity, a risk factor for surgical wound infections due to impaired tissue perfusion, reduced immune response, and prolonged healing. Excess adipose tissue increases infection likelihood, aligning with evidence-based risk factors, making this the correct finding to identify.
Choice B reason: A temperature of 36.8°C is normal and does not indicate infection risk. Fever (>38°C) post-surgery might suggest infection, but this value reflects stable physiology, making it an incorrect indicator for assessing wound infection risk in this client.
Choice C reason: A white blood cell count of 8,000/mm³ is within normal range (5,000-10,000/mm³) and does not indicate infection risk. Elevated counts suggest active infection, but this value is unremarkable, making it incorrect for identifying infection risk post-surgery.
Choice D reason: A blood glucose of 90 mg/dL is normal (74-106 mg/dL) and does not increase infection risk. Hyperglycemia (>140 mg/dL) impairs immune function, but this value indicates good control, making it incorrect for assessing wound infection risk.

A. I prefer to wear loose clothing to hide my scars. B. I am ready to join a support group for cancer survivors. C. I feel confident about my recovery process. D. I am planning to resume my exercise routine next week.

Correct Answer is A

Explanation

Choice A reason: Preferring loose clothing to hide scars indicates an altered body image, as it reflects discomfort with physical changes post-mastectomy. This behavior suggests emotional distress about appearance, a common response to surgical body alterations, making it the correct indicator.
Choice B reason: Joining a support group shows proactive coping and acceptance, not necessarily an altered body image. It reflects social engagement and resilience, not distress about physical changes, making it incorrect for indicating body image concerns.
Choice C reason: Feeling confident about recovery suggests positive adjustment, not an altered body image. Confidence indicates emotional resilience rather than distress about physical appearance post-mastectomy, making this statement incorrect for this concern.
Choice D reason: Planning to resume exercise indicates focus on recovery and health, not body image distress. This proactive attitude reflects physical rehabilitation goals, not emotional concerns about appearance, making it incorrect for altered body image.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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Correct Answer is A

Explanation

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