A nurse is assisting in the care of a client who is in restraints following an episode of violence. Which of the following information should the nurse document in the client's medical record? (Select all that apply.)

Providing opportunities for nutrition and toileting

Observing range of motion of client's extremities

Observation of the client once per hour

Attempts at less restrictive interventions

Names of staff members caring for the client

Answer and Explanation

Correct Answer : A,B,D,E

A.   It is essential to document the times when the client was offered opportunities for nutrition and toileting while in restraints. This includes offering food and fluids at regular intervals and assisting the client with toileting needs as required. Documentation ensures that these basic needs are met despite the restraint status.
B.   Documenting observations of the client's range of motion helps monitor for any signs of discomfort, circulation issues, or injury related to being in restraints. This documentation is crucial for ensuring the client's safety and well-being during restraint use.
C.   observation of the client should be conducted more frequently than once per hour, especially after an episode of violence, to closely monitor the client's condition and response to the restraints.
D.   Documenting attempts at less restrictive interventions shows that the healthcare team is actively working to minimize the use of restraints whenever possible. This might include attempts to de-escalate the client, use of medications, or other interventions aimed at reducing agitation or violence without resorting to physical restraints.
E.   It is important to document the names of staff members who are directly involved in the care of a restrained client. This ensures accountability and provides a clear record of who has been caring for the client during their restraint period.

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Correct Answer is B

Explanation

A. Cognitive behavioral therapy (CBT) is a commonly used psychotherapy approach for bipolar disorder. Attending a CBT class typically does not require specific informed consent beyond the general consent for treatment, as it involves non-invasive, non-experimental therapeutic techniques aimed at improving coping skills and managing symptoms. In most cases, attending therapy sessions like CBT is considered part of routine care for mental health conditions.
B. Experimental medications involve drugs or treatments that are not yet approved by regulatory agencies (such as the FDA in the United States) for general use. For a client to participate in a clinical trial or receive an experimental medication, they must provide explicit informed consent after being informed about the potential risks, benefits, and uncertainties associated with the treatment. This process ensures that the client understands they are participating in research and not receiving standard care.
C. Participating in a group exercise program is generally considered a routine therapeutic intervention aimed at promoting physical health and well-being. While informed consent is important for all interventions, including exercise programs, it typically involves providing general information about the program's goals, activities, and any potential risks. Clients are not consenting to experimental treatments or procedures that go beyond standard exercise protocols.

D. Light therapy, also known as phototherapy, is a treatment often used for seasonal affective disorder (SAD) and other mood disorders. It involves exposure to specific wavelengths of light to regulate circadian rhythms and improve mood. While light therapy is a specialized treatment, it is a standard intervention for mood disorders and does not typically require separate informed consent beyond what is provided for standard medical treatments.

A. Incoordination B. Polyuria C. Nausea D. Convulsions E. Confusion

Correct Answer is ["A","C","E"]

Explanation

A. Incoordination, such as clumsiness or difficulty walking, can be an early sign of lithium toxicity. It reflects the neurological effects of elevated lithium levels on motor coordination.
B. Polyuria (excessive urination) is a common late symptom of lithium toxicity. Lithium interferes with the kidney's ability to concentrate urine, leading to increased urine output.
C. Nausea is a gastrointestinal symptom that can occur in the early stages of lithium toxicity. It is often accompanied by other gastrointestinal disturbances such as vomiting and diarrhea.
D. Convulsions (seizures) are not typically considered early manifestations of lithium toxicity but rather indicate severe toxicity. Seizures can occur at higher levels of lithium toxicity and require immediate medical intervention.
E. Confusion is another early sign of lithium toxicity. It reflects the impact of elevated lithium levels on the central nervous system, leading to cognitive impairment and altered mental status.

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A nurse is assisting in the care of a client who is in restraints following an episode of violence. Which of the following information should the nurse document in the client's medical record? (Select all that apply.)

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Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a client who has bipolar disorder and whose admission was voluntary. For which of the following interventions should the nurse confirm that the client has given informed consent?

Correct Answer is B

Explanation

A nurse is collecting data from a client who is taking lithium. Which of the following findings should the nurse identify as early manifestations of lithium toxicity? (Select all that apply.)

Correct Answer is ["A","C","E"]

Explanation

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