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.

Answer and Explanation

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.

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Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}

Explanation

Rationale for correct choices:

Obtain IV access: The client has hypotension (BP 90/50 mm Hg), tachycardia (HR 118/min), and significant anemia (Hgb 9.1 g/dL, Hct 27%), all of which suggest possible active gastrointestinal bleeding. Establishing IV access is a priority to allow rapid fluid resuscitation or blood product administration as needed.
Prepare for a blood transfusion: Given the positive hemoccult stool, anemia, and vital sign changes, the client may require a blood transfusion to restore hemodynamic stability and oxygen-carrying capacity. Preparing for transfusion ensures timely intervention in case of worsening blood loss.

Rationale for incorrect choices:

Call the surgical suite to notify that the client is arriving STAT: While the client is scheduled for endoscopy, immediate stabilization takes priority over notifying the surgical suite. The client’s hemodynamic status must be addressed first to prevent deterioration.
Recheck the client's oxygen saturation: The client’s oxygen saturation is 98% on room air, which is within normal limits. Rechecking is not immediately necessary and does not address the urgent need for stabilization.
Place the client in a supine position with feet elevated: Although elevating the feet can help improve perfusion temporarily, it does not treat the underlying anemia or hypotension and is less urgent than establishing IV access and preparing for transfusion.
Offer oral fluids: Oral intake is contraindicated in a client at risk for endoscopy and possible GI bleeding. Fluids could increase the risk of aspiration and do not address hemodynamic instability.
Administer PRN antacids: Antacids may provide minor symptom relief but do not treat active blood loss or stabilize the client before endoscopy.
Document vital signs: Documentation is important but secondary to immediate interventions that address the client’s hypotension and potential hemorrhage.

A. WBC count 6,700/mm3 (5,000 to 10,000/mm3) B. Hemoglobin 12 g/dL (14 to 18 g/dL) C. Hematocrit 36% (40% to 52%) D. Blood pressure 112/74 mm Hg E. Heart rate 95/min F. Respiratory rate 18 G. Temperature 37.5(99.5° F)

Correct Answer is ["B","C","D","E"]

Explanation

Rationale for correct choices:

Hemoglobin 12 g/dL: The increase from 9.1 g/dL to 12 g/dL indicates that the client’s anemia is resolving. This suggests effective treatment or stabilization following blood loss, improving oxygen-carrying capacity and overall perfusion.
Hematocrit 36%: The rise from 27% to 36% reflects an improvement in the proportion of red blood cells in circulation. This correlates with better tissue oxygenation and a positive response to interventions such as a blood transfusion.
Blood pressure 112/74 mm Hg: The increase from 90/50 mm Hg indicates improved hemodynamic stability. This suggests the client is no longer hypovolemic and is better able to maintain adequate perfusion to vital organs.
Heart rate 95/min: The decrease from 118/min shows a reduction in compensatory tachycardia. This reflects improved circulatory status and decreased physiological stress following stabilization of blood volume and oxygenation.

Rationale for incorrect choices:

WBC count 6,700/mm³: The WBC count remains unchanged from admission. While within normal limits, it does not specifically indicate improvement in anemia or hemodynamic status, which are the primary concerns in this scenario.
Respiratory rate 18/min: The respiratory rate is unchanged and within normal limits. Although stable, it does not provide a direct measure of improvement in anemia or perfusion.
Temperature 37.5°C (99.5°F): The temperature is stable but slightly elevated. While not concerning, it does not reflect a specific improvement in the client’s primary condition.

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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?

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Naxlex Comprehensive Predictor Exams

The nurse is obtaining the client's vital signs prior to an endoscopy. Exhibits Complete the following sentence by using the list of options The nurse should first anticipate to dropdown then dropdown.

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}

Explanation

Correct Answer is ["B","C","D","E"]

Explanation

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