A nurse is assisting in the care of a client who was placed in mechanical restraints due to physical violence. Which of the following actions should the nurse take?

Offer the client fluids and toileting every 15 min.

Obtain a prescription before removing the restraints.

Ensure the restraints are removed from the client within 6 hr.

Place the client in prone position on a soft mattress.

Answer and Explanation

The Correct Answer is B

Rationale:

A. Offer the client fluids and toileting every 15 min: While regular offering of fluids and toileting is essential, the standard protocol is typically every 2 hours not every 15 minutes unless otherwise indicated. Overly frequent checks may not be feasible or necessary unless clinically justified.

B. Obtain a prescription before removing the restraints: Mechanical restraints are considered a restrictive intervention and require a physician's order for both application and removal. This ensures medical oversight and client safety.

C. Ensure the restraints are removed from the client within 6 hr: Time limits for restraints depend on the client’s age. For adults, a new order must be obtained every 4 hours, not 6. For children and adolescents (9-17 years), it's 2 hours, and for children under 9 years, it's 1 hour.

D. Place the client in prone position on a soft mattress: Prone restraint positions are not safe and are strongly discouraged due to risk of asphyxiation or injury. Restraints should always allow for safe positioning, typically with the client in a supine or semi-Fowler’s position.

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Correct Answer is B

Explanation

Rationale:

A. "This surgery can cause an increase in the amount of semen.":A transurethral resection of the prostate (TURP) often results in retrograde ejaculation, meaning semen may flow backward into the bladder. The volume of visible semen typically decreases, not increases, due to this common complication.

B. "I will talk to my partner about other ways of expressing intimacy.":This statement reflects healthy psychological adjustment and understanding of potential changes in sexual function following TURP. It shows emotional readiness to adapt to changes and maintain intimacy in ways beyond penetrative sex, which supports recovery and relationship stability.

C. “I will not be able to have sexual intercourse after this surgery.":TURP does not prevent sexual intercourse. While temporary issues like erectile dysfunction or retrograde ejaculation may occur, most clients can resume sexual activity after recovery. This belief represents a misunderstanding of surgical outcomes.

D. “This surgery will prevent me from being able to have an erection.": Although some men may experience temporary erectile dysfunction postoperatively, TURP typically does not cause permanent loss of erectile function. Misconceptions about impotence should be addressed through accurate education.

A. Erythema toxicum B. Bacterial vaginosis C. Molluscum contagiosum D. Gonorrhea

Correct Answer is D

Explanation

Rationale:

A. Erythema toxicum: This is a common and benign rash seen in newborns. It is not infectious, poses no public health risk, and does not require mandatory reporting.

B. Bacterial vaginosis: Although it is a vaginal infection, bacterial vaginosis is not classified as a reportable condition. It does not pose the same level of public health concern as sexually transmitted infections like gonorrhea.

C. Molluscum contagiosum: Molluscum contagiosum is a viral skin infection that is generally self-limiting and not considered a reportable disease. It does not require public health intervention in most cases.

D. Gonorrhea: Gonorrhea is a nationally notifiable disease in many countries, including the United States, due to its infectious nature and potential for serious complications. Public health reporting is required to track, treat, and prevent its spread.

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A nurse is assisting in the care of a client who was placed in mechanical restraints due to physical violence. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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