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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

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

Explanation

A. Individuals with ASPD often exhibit manipulative behaviors to exploit others for their own gain or pleasure. They may be deceitful and use charm or manipulation to achieve their goals.
B. This finding is not typically associated with ASPD. Instead, individuals with ASPD tend to focus on immediate gratification and may have difficulty with long-term planning or sustained attention.
C. People with ASPD typically have a reduced ability to empathize with others. They may disregard the feelings, rights, and sufferings of others, and show little remorse for their actions.
D. Splitting refers to a defense mechanism where individuals tend to view people, situations, or events as either all good or all bad. While this can occur in personality disorders like borderline personality disorder, it is not a characteristic feature of ASPD.
E. Impulsivity is a common trait in individuals with ASPD. They often act without considering the consequences of their actions, leading to risky behaviors such as substance abuse, reckless driving, or criminal activities.

A. Lanugo B. Muscle wasting C. Hypomagnesemia D. Hypokalemia

Correct Answer is D

Explanation

A. Lanugo refers to fine, soft hair that grows on the face, back, and arms as a result of malnutrition. It is more common in anorexia nervosa rather than bulimia nervosa.
B. Muscle wasting is not typically a primary symptom of bulimia.
C. Hypomagnesemia, or low magnesium levels, may occur but is not very characteristic of bulimia nervosa.
D. Hypokalemia, or low levels of potassium in the blood, is a common finding in individuals with bulimia nervosa who engage in purging behaviors such as vomiting or misuse of diuretics. Potassium is crucial for proper muscle and nerve function, and low levels can lead to symptoms such as muscle weakness, fatigue, cardiac arrhythmias, and in severe cases, paralysis.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has antisocial personality disorder. Which of the following findings should the nurse expect? (Select all that apply.)

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

Explanation

A nurse is collecting data from a client who has bulimia nervosa. Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

A nurse in a mental health facility is caring for a client who has antisocial personality disorder and alcohol dependency. The nurse should encourage the client to participate in which of the following groups?

A nurse is preparing to administer sertraline 50 mg PO once daily to a client who has depressive disorder. Available is sertraline oral solution 20 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.

A nurse is assisting in the care of a client who is scheduled to receive electroconvulsive therapy (ECT). Which of the following is the nurse's role during the informed consent process?

A nurse is caring for a client who was placed in four-point restraints by the nursing staff following an episode of violent behavior. Which of the following actions should the nurse take?

A nurse is caring for a client who is receiving acute care for the treatment of a substance use disorder. With which of the following actions is the nurse demonstrating the ethical principle of veracity?

A nurse is providing information to a client about smoking cessation. Which of the following medications should the nurse include?

A nurse is collecting data from an older adult client who was admitted with heart failure. The nurse should report which of the following findings to the provider as an indication of delirium?

A nurse is collecting data for a health history from a client who has antisocial personality disorder. Which of the following clinical findings is associated with this disorder?