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 B
Explanation
Choice A reason: Performing postural drainage immediately after meals risks aspiration and discomfort due to gastric contents shifting during positioning. It should be done 1-2 hours after meals to ensure safety and efficacy in clearing mucus from the lungs, making this timing inappropriate for cystic fibrosis management.
Choice B reason: Performing postural drainage twice daily is recommended for cystic fibrosis to mobilize thick mucus from the lungs, improving airway clearance and reducing infection risk. This frequency balances effectiveness with patient tolerance, aligning with evidence-based guidelines for managing chronic respiratory conditions, making it the correct action.
Choice C reason: Using a percussion vest is an alternative to manual postural drainage but is not specified as the only method. Manual techniques are effective and standard unless a vest is prescribed. This choice assumes equipment availability, which may not apply, making it less universally appropriate than scheduled manual drainage.
Choice D reason: Positioning the child flat during postural drainage is incorrect, as specific angled positions (e.g., head-down) are needed to target lung segments and promote mucus drainage by gravity. Flat positioning reduces effectiveness and may not clear airways adequately, making this an inappropriate technique for cystic fibrosis.
Correct Answer is B
Explanation
Choice A reason: Preparing for a paracentesis is inappropriate, as abdominal distention post-laparoscopic cholecystectomy is typically due to retained carbon dioxide from insufflation, not ascites. Paracentesis is invasive and unnecessary, risking complications without addressing the cause, making it an incorrect intervention for this scenario.
Choice B reason: Assisting the client to ambulate promotes the expulsion of residual gas used during laparoscopic cholecystectomy, relieving abdominal distention. Early mobility enhances circulation, reduces bloating, and prevents complications like ileus, aligning with postoperative care guidelines, making it the most effective and appropriate action.
Choice C reason: Inserting a rectal suppository is not indicated, as distention is likely from gas, not constipation, immediately post-cholecystectomy. Suppositories may cause discomfort without resolving gas-related bloating. This intervention is premature and misaligned with the cause, making it inappropriate.
Choice D reason: Placing the client in the prone position may worsen discomfort from abdominal distention by compressing the abdomen, trapping gas. Upright or walking positions facilitate gas movement and relief. This position is counterproductive, making it an incorrect choice for managing post-surgical distention.
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