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?
Hold a critical incident debriefing about the client.
Observe the client’s range of movement.
Maintain sensory stimulation for the client.
Identify stressors that caused the client’s aggression.
The Correct Answer is B
Choice A reason: Holding a debriefing is post-incident, not a priority during restraint use; observing movement ensures safety. Assuming debriefing is immediate risks neglecting client monitoring, potentially causing injury, critical to avoid in ensuring safe restraint use and client well-being in acute behavioral situations.
Choice B reason: Observing range of movement during restraints ensures proper application, preventing injury like nerve damage or circulation issues, critical for client safety. This ongoing assessment adheres to restraint protocols, essential for minimizing harm, ensuring ethical care, and supporting de-escalation in aggressive clients.
Choice C reason: Maintaining sensory stimulation is inappropriate during restraints, as it may escalate agitation; observing movement is priority. Assuming stimulation is needed risks worsening aggression, potentially prolonging restraint use, critical to avoid in ensuring calm and safe management of clients in mechanical restraints.
Choice D reason: Identifying stressors is important but secondary to ensuring physical safety by observing movement during restraints. Assuming stressors are the immediate focus risks neglecting restraint safety, potentially causing injury, critical to prevent in ensuring proper monitoring and care in aggressive client situations.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Smallpox vaccination is not routine due to eradication; disaster preparedness involves drills. Assuming vaccination is relevant risks misaligned priorities, diverting resources from practical preparedness, critical to avoid in ensuring nurses contribute effectively to community readiness for various disaster scenarios.
Choice B reason: Quarantine for anthrax is specific and reactive, not a primary preparedness activity; drills are broader. Assuming quarantine planning is key risks neglecting comprehensive disaster training, critical to prevent in ensuring nurses are prepared for diverse emergencies through community mock events.
Choice C reason: Assessing disaster types and scopes is typically administrative, not a nurse’s primary role; drills are practical. Assuming assessment is the focus risks overlooking hands-on preparedness, critical to avoid in ensuring nurses gain skills through community drills for effective disaster response.
Choice D reason: Participating in community drills and mock events prepares nurses for disaster response, enhancing skills in triage and coordination, critical for effective emergency management. This ensures readiness, improves response efficiency, and supports community safety, essential for nurses in disaster preparedness roles across various scenarios.
Correct Answer is C
Explanation
Choice A reason: Nonlatex gloves are relevant for allergies, not droplet precautions, which require masks. Placing surgical masks is key. Assuming gloves are priority risks neglecting respiratory protection, potentially increasing transmission, critical to avoid in ensuring effective infection control for droplet-borne illnesses in healthcare settings.
Choice B reason: HEPA filtration is for airborne precautions, not droplet, which needs masks. Placing surgical masks is correct. Assuming HEPA is needed risks misapplying resources, potentially diverting focus from droplet transmission prevention, critical to prevent in ensuring proper infection control for clients on droplet precautions.
Choice C reason: Placing surgical masks outside the room is essential for droplet precautions, ensuring staff and visitors wear masks to prevent respiratory transmission. This is critical for infection control, reducing spread, protecting others, and adhering to CDC guidelines for managing droplet-borne infections in healthcare settings.
Choice D reason: Negative pressure rooms are for airborne precautions, not droplet, which requires masks. Assuming negative pressure is needed risks inappropriate room assignment, potentially increasing transmission, critical to avoid in ensuring correct infection control measures for clients on droplet precautions in healthcare facilities.
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