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 C
Explanation
Choice A reason: Wrapping sterile gauze for bleeding is inappropriate; gentle pressure and provider notification are needed. Petroleum jelly prevents adhesion. Using gauze risks infection or trauma, critical to avoid in ensuring safe circumcision healing, supporting parental care, and preventing complications in newborns post-procedure.
Choice B reason: Removing yellow exudate, a normal healing sign, risks disrupting the circumcision site, causing pain or infection. Petroleum jelly is correct. Assuming removal is needed risks delayed healing, critical to prevent in ensuring proper wound care and parental education for newborns post-circumcision.
Choice C reason: Applying petroleum jelly to the glans with diaper changes prevents diaper adhesion, promotes healing, and reduces discomfort post-circumcision. This instruction is critical for parental care, ensuring infection prevention, supporting newborn comfort, and facilitating proper healing in the sensitive post-procedure period.
Choice D reason: Using soap on the circumcision site risks irritation and delayed healing; gentle water cleansing is preferred. Petroleum jelly is appropriate. Assuming soap is safe risks discomfort or infection, critical to avoid in ensuring proper care and healing for newborns following circumcision procedures.
Correct Answer is D
Explanation
Choice A reason: Discussing communication methods addresses client behaviors but not the caregiver’s stress from constant care. A daycare program offers respite. Focusing on communication risks neglecting caregiver well-being, potentially worsening burnout, critical to avoid in supporting caregivers of Alzheimer’s clients with high care demands.
Choice B reason: Suggesting antipsychotics for the client addresses behavior but not caregiver stress, and is inappropriate without medical evaluation. Daycare provides relief. Assuming medication is the solution risks unnecessary drug use, potentially causing side effects, critical to avoid in supporting caregiver health and client safety.
Choice C reason: Allowing the client time alone is unsafe for Alzheimer’s patients due to wandering risks and does not relieve caregiver stress. Daycare is effective. Assuming alone time helps risks client safety and caregiver burden, critical to prevent in ensuring comprehensive care for Alzheimer’s clients and caregivers.
Choice D reason: Assisting with a daycare program provides respite, reducing caregiver stress and preventing burnout while ensuring client safety. This intervention supports caregiver well-being, critical for sustained care quality, promoting mental health, and enabling effective management of Alzheimer’s disease in home settings with high care demands.
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