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 ["A","D","E"]

Explanation

Rationale:

A. Limit visitors to 30 min per day: Time restrictions help reduce others’ exposure to radiation from the sealed implant. Limiting duration minimizes cumulative exposure for visitors while still allowing social interaction for the client.

B. Place the client in a semi-private room: Clients with internal radiation implants require a private room to protect others from unnecessary radiation exposure. A semi-private room increases the risk of radiation exposure to other patients and is inappropriate.

C. Instruct visitors who are pregnant to remain 3 feet from the client: Pregnant visitors should avoid contact with clients receiving internal radiation entirely, as even minimal exposure could harm the fetus. The safest recommendation is to avoid visiting during treatment.

D. Wear a lead apron when providing care: A lead apron shields the nurse from radiation exposure, especially when working close to the client. This is part of the time, distance, and shielding principles for radiation safety.

E. Close the door to the client's room: Keeping the door closed helps contain radiation within the client’s room, reducing exposure to staff and visitors in nearby areas. This is a standard precaution in caring for clients with sealed implants.

A. "You will need to change the IV dressing site once per week." B. "You will need to warm the solution in the microwave before administration." C. "You will need to weigh the client twice per week." D. "You will need to monitor the client's electrolytes daily."

Correct Answer is D

Explanation

Rationale:

A. "You will need to change the IV dressing site once per week.": Central line dressings for TPN are typically changed every 48–72 hours for gauze or every 5–7 days for transparent dressings, or sooner if the dressing becomes damp, loose, or soiled, to reduce infection risk.

B. "You will need to warm the solution in the microwave before administration.": TPN solutions should never be microwaved due to the risk of uneven heating and nutrient degradation. They should be administered at room temperature.

C. "You will need to weigh the client twice per week.": Clients receiving TPN require daily weights to monitor fluid balance, nutritional status, and detect fluid retention or dehydration promptly. Twice-weekly measurements are insufficient for close monitoring.

D. "You will need to monitor the client's electrolytes daily.": TPN can cause rapid changes in fluid and electrolyte balance, so daily electrolyte monitoring allows timely adjustments to prevent complications such as hypo- or hypernatremia, hypokalemia, and metabolic imbalances.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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