A nurse is caring for a client who became physically aggressive and had to be placed in mechanical restraints. Which of the following actions should the nurse take while the client is in restraints?
Observe the client's range of movement.
Identify stressors that caused the client's aggression.
Hold a critical incident debriefing about the client.
Maintain sensory stimulation for the client.
The Correct Answer is B
A. Observe the client's range of movement: While monitoring physical status is important, mechanical restraints restrict movement, so assessing the client’s psychological triggers and safety is higher priority to prevent further aggression.
B. Identify stressors that caused the client's aggression: Understanding and addressing the factors that led to aggressive behavior is essential while the client is in restraints. This assessment helps in developing strategies to reduce agitation and prevent future episodes.
C. Hold a critical incident debriefing about the client: Debriefing is conducted after the event to support staff and evaluate interventions. It is not performed while the client is actively restrained.
D. Maintain sensory stimulation for the client: Providing excessive sensory stimulation during restraint can increase agitation and risk of injury. The focus should be on calming the client and ensuring safety rather than maintaining stimulation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. The child believes the person will return: Preschoolers view death as temporary and reversible due to their developmental stage and limited understanding of permanence. Magical thinking often leads them to expect the deceased person to come back.
B. The child focuses on his own mortality: This is more typical of older school-age children or adolescents, who have a more developed understanding of death’s permanence and may begin to consider their own vulnerability.
C. The child refuses to talk about the death: Avoidance can occur at any age, but it is not the primary expected response in preschoolers. At this stage, they may ask repetitive questions or make statements that suggest misunderstanding, rather than complete refusal to talk.
D. The child expresses curiosity about the death process: Curiosity about death’s physical aspects is more common in school-age children, who have greater cognitive ability to think concretely about biological processes.
Correct Answer is D
Explanation
A. Patient-centered care: This competency focuses on respecting client preferences, values, and needs while involving them in care decisions. Completing an incident report does not directly address individualized client care.
B. Evidence-based practice: Evidence-based practice involves integrating the best current research evidence with clinical expertise and patient values. Documenting an incident report is not based on reviewing or applying research evidence.
C. Informatics: Informatics involves using information technology to communicate, manage knowledge, and support decision-making. While an incident report may use electronic systems, the primary purpose is not focused on informatics competency.
D. Quality improvement: Completing an incident report identifies errors, near misses, or adverse events, which helps the healthcare team analyze processes and implement changes to improve patient safety. This reflects the quality improvement competency by contributing to safer care systems.
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