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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Offering the breast at hunger cues, like rooting, supports demand feeding, regulating milk supply via prolactin. This ensures adequate nutrition and bonding, critical for infant growth and lactation success, aligning with evidence-based breastfeeding practices for optimal maternal-infant outcomes.
Choice B reason: Limiting feeding to 10 minutes per breast restricts hindmilk intake, rich in fat, reducing nutrition and milk supply. Fixed timing disrupts prolactin-driven lactation, risking inadequate weight gain, contrary to breastfeeding guidelines recommending unrestricted feeding based on infant cues.
Choice C reason: Starting each feeding with the same breast risks unbalanced milk production and engorgement. Alternating breasts ensures even stimulation and emptying, maintaining supply and preventing complications, making this incorrect for supporting effective breastfeeding practices in new parents.
Choice D reason: Feeding every 6 hours is too infrequent for newborns, needing feeds every 2-3 hours to meet nutritional demands and stimulate milk production. Fixed schedules ignore hunger cues, risking dehydration or poor growth, contradicting evidence-based breastfeeding recommendations for infants.
Correct Answer is A
Explanation
Choice A reason: Using three-pronged grounded plugs ensures proper grounding, reducing the risk of electrical fires by safely dissipating excess current. This prevents shocks and short circuits, aligning with National Fire Protection Association (NFPA) standards. Grounded plugs are essential for safe appliance use, making this a critical recommendation for fire prevention education.
Choice B reason: Checking for a tingling sensation around a cord is not a reliable or safe method for fire prevention. Tingling may indicate electrical faults, but proactive measures like inspecting cords for fraying or overheating are more effective. This approach is reactive and risky, as it does not prevent fires, making it inappropriate.
Choice C reason: Covering extension cords with a rug traps heat and increases wear, raising the risk of electrical fires. Cords should be exposed to air and placed to avoid damage or tripping hazards. This practice violates safety guidelines, as it conceals potential issues, making it an incorrect recommendation for fire prevention.
Choice D reason: Removing a plug by pulling the cord can damage insulation or wiring, increasing fire risk due to exposed conductors or short circuits. Plugs should be grasped firmly at the base to remove safely. This action is unsafe and contradicts electrical safety standards, making it an incorrect teaching point.
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