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 B
Explanation
A. Instruct the client to flex the right knee every 30 min: After a femoral cardiac catheterization, the affected leg should remain straight to prevent bleeding or hematoma formation. Flexing the knee could disrupt hemostasis at the insertion site.
B. Assess the client's peripheral pulses every 15 min: Frequent monitoring of peripheral pulses ensures early detection of vascular complications such as thrombosis, occlusion, or impaired circulation in the affected limb.
C. Change the client's dressing 4 hr following the procedure: The initial dressing is typically left intact for several hours or until bleeding is controlled. Early dressing changes are unnecessary and may increase infection risk.
D. Elevate the head of the client's bed to 45°: Elevating the head of the bed can increase pressure on the femoral insertion site and risk bleeding. The client’s bed is usually kept flat or slightly elevated according to provider orders until hemostasis is confirmed.
Correct Answer is A
Explanation
A. Bradypnea: Hypermagnesemia depresses neuromuscular and central nervous system function, which can lead to slowed respiratory rate (bradypnea) and potentially respiratory failure in severe cases.
B. Personality change: Personality changes are more commonly associated with hyponatremia, hypernatremia, or other electrolyte imbalances affecting the brain, rather than hypermagnesemia.
C. Seizure: Seizures are more likely in hypomagnesemia due to increased neuromuscular excitability, not in hypermagnesemia, which generally causes neuromuscular depression.
D. Elevated hematocrit: Hypermagnesemia does not directly affect red blood cell concentration or hematocrit levels. Changes in hematocrit are usually related to fluid volume status, not magnesium levels.
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