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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

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

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

A. Monitoring liver enzymes (AST, ALT) is typically not directly related to lithium therapy. Elevated liver enzymes may indicate liver damage from various causes, such as hepatitis or medication toxicity, but it is not a routine monitoring parameter for lithium.
B. Lithium can decrease the excretion of uric acid, potentially leading to elevated levels. Monitoring uric acid levels helps to detect hyperuricemia, which may contribute to conditions like gout. It's important to monitor this parameter periodically during lithium therapy.
C. ESR is a nonspecific marker of inflammation and is not specifically monitored in relation to lithium therapy. It is used to diagnose or monitor conditions like infections, autoimmune diseases, or certain cancers, but it does not directly relate to lithium use.
D. Monitoring serum sodium levels is crucial during lithium therapy because lithium can affect renal function and electrolyte balance, including sodium levels. Hyponatremia is a potential adverse effect of lithium, and regular monitoring helps detect and manage this condition promptly.

A. Acknowledge an inability to control drinking. B. Agree to a prescription for an alcohol use deterrent. C. Form a close support network. D. Incorporate a form of spirituality into daily life.

Correct Answer is A

Explanation

A. This is a crucial first step in recovery. It involves recognizing and accepting that one has lost control over their drinking and that alcohol use is causing negative consequences in their life. Without acknowledging this lack of control, individuals may not be motivated to seek or engage in treatment.
B. While medications such as disulfiram (Antabuse) or naltrexone (Revia) can be part of a comprehensive treatment plan for alcohol use disorder, agreeing to a prescription for an alcohol use deterrent is not typically the first step in recovery. It usually follows assessment, acknowledgment of the problem, and development of a treatment plan in collaboration with healthcare providers.
C. Building a strong support network is indeed crucial for long-term recovery. This network may include family, friends, peers in recovery, and support groups like Alcoholics Anonymous (AA). However, forming this support network is often a step that occurs as part of ongoing treatment and recovery efforts rather than the very first step.

D. Incorporate a form of spirituality into daily life: Spirituality or a sense of purpose can be a significant component of recovery for some individuals, providing strength and motivation. However, it is not universally considered the first step in recovery. Spirituality may be explored and integrated into the recovery journey as individuals progress in treatment and self-discovery.

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 reinforcing teaching with a client who has bipolar disorder and has a new prescription for lithium. To address possible adverse effects, the nurse should include that which of the following laboratory values will be monitored while the client is taking this medication?

Correct Answer is D

Explanation

A nurse in a substance use disorder clinic is explaining the alcohol recovery process to a client's family. Which of the following should the nurse identify as the first step toward successful recovery from alcohol use disorder?

Correct Answer is A

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 reinforcing behavior management techniques with the parent of a school-age child who has conduct disorder. Which of the following statements by the parent indicates an understanding of the redirection technique?

A nurse is caring for a client who is receiving treatment for alcohol detoxification. Which of the following medications should the nurse expect to administer during this phase of the client's care?

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

A nurse is reinforcing teaching with a newly licensed nurse about client confidentiality. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

A nurse is contributing to the plan of care for a client who is to start therapy with fluoxetine. Which of the following is an expected outcome for this client?

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.)