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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. A colleague who uses assertive communication: Assertive communication is a positive professional skill that promotes clarity and mutual respect. It involves expressing needs and opinions confidently while respecting the rights of others, not bullying behavior.
B. A colleague who is mindful of the personal space of other colleagues: Respecting personal space reflects professional courtesy and helps maintain a comfortable work environment. It does not represent any form of bullying or intimidation.
C. A colleague who negotiates with others for a win-win situation: Negotiation aimed at mutual benefit demonstrates collaboration and problem-solving, which are constructive workplace behaviors, not bullying tactics.
D. A colleague who finds fault with other colleagues: Habitually criticizing or fault-finding without constructive intent is a form of workplace bullying. This behavior undermines morale, creates a hostile environment, and can damage professional relationships.
Correct Answer is C
Explanation
A. Apply lidocaine gel around the incision: Topical lidocaine is generally used for localized superficial pain, not for deep postoperative pain following major joint surgery. Its effectiveness for a knee arthroplasty incision is limited.
B. Attach a transcutaneous electrical nerve stimulation unit around the incision: TENS units can help with some types of pain but are more effective for chronic musculoskeletal pain rather than acute postoperative pain.
C. Place a cold pack over the incision: Cold therapy reduces inflammation, swelling, and pain in the immediate postoperative period. It is a safe and effective nonpharmacological intervention for mild to moderate pain following knee arthroplasty.
D. Assist the client for a walk in the hallway: Early ambulation is important for preventing complications and promoting recovery, but it may initially increase pain when the client is only 4 hours post-surgery. Cold therapy is more appropriate for immediate pain relief.
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