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 D

Explanation

Choice A reason: Red meat is high in saturated fats and sodium, which can elevate blood pressure, worsening hypertension. It is not recommended for a heart-healthy diet, as it increases cardiovascular strain. The nurse should suggest leaner proteins instead, making this an incorrect dietary choice.
Choice B reason: Cheese is often high in sodium and saturated fat, contributing to increased blood pressure and cardiovascular risk in hypertension. Low-sodium alternatives are preferred, but cheese is generally discouraged, making this an inappropriate food to recommend for this client’s diet.
Choice C reason: Canned black beans are high in sodium, which exacerbates hypertension by promoting fluid retention and vascular strain. Rinsing reduces sodium, but fresh or low-sodium options are better. This choice is less ideal than fresh produce, making it incorrect for hypertension management.
Choice D reason: Fresh spinach is rich in potassium, magnesium, and fiber, which help lower blood pressure by counteracting sodium and relaxing blood vessels. It aligns with the DASH diet, an evidence-based approach for hypertension, making it the best food to recommend for this client’s condition.

A. I will remove gluten from my diet. B. I will remove peanuts from my diet. C. I will avoid bananas. D. I will avoid dairy products.

Correct Answer is C

Explanation

Choice A reason: Gluten removal is unrelated to latex allergy, which involves immune responses to latex proteins. Gluten pertains to celiac disease, not latex-fruit syndrome. Avoiding gluten does not prevent allergic reactions to latex, making this an incorrect understanding of latex allergy management.
Choice B reason: Peanuts are linked to peanut allergies, not latex. Latex allergy involves IgE-mediated reactions to rubber proteins, not peanut proteins. While allergies may coexist, peanuts lack cross-reactivity with latex, making avoidance irrelevant for managing latex allergy symptoms or risks.
Choice C reason: Avoiding bananas is correct due to latex-fruit syndrome, where latex proteins cross-react with banana proteins like chitinases, causing allergic reactions (e.g., itching, anaphylaxis). This understanding ensures clients avoid trigger foods, reducing risk of allergic responses in latex-sensitive individuals.
Choice D reason: Dairy products are not linked to latex allergy, as they lack cross-reactive proteins. Latex reactions stem from exposure to rubber or related plant proteins, not milk. Avoidance is unnecessary, as dairy does not trigger the immunological responses associated with latex allergy.

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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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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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