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: A communication board is for speech or cognitive issues, not visual impairment, where indirect lighting aids vision. Assuming a board is appropriate risks ineffective communication, potentially frustrating the client, critical to avoid in ensuring clear interaction for visually impaired clients in care settings.
Choice B reason: An interpreter is for language barriers, not visual impairment, where indirect lighting enhances visibility. Assuming an interpreter is needed risks misaligned communication strategies, potentially reducing clarity, critical to prevent in ensuring effective teaching and interaction for clients with visual impairments.
Choice C reason: Indirect lighting reduces glare, improving visibility for visually impaired clients, enhancing communication and safety. This understanding is critical for effective interaction, ensuring client comfort, promoting independence, and supporting accurate information exchange, essential for care delivery in clients with visual impairments.
Choice D reason: Collaborating with a speech therapist addresses speech issues, not visual impairment, where indirect lighting is key. Assuming therapist involvement is relevant risks overlooking visual needs, potentially reducing communication efficacy, critical to avoid in supporting visually impaired clients in healthcare settings.
Correct Answer is D
Explanation
Choice A reason: Increased blood pressure is not an effect of furosemide, which reduces fluid volume, lowering pressure. Weight loss indicates efficacy. Assuming increased pressure is correct risks misinterpreting diuresis, potentially delaying further fluid management, critical to avoid in treating fluid volume excess effectively.
Choice B reason: Decreased pain is unrelated to furosemide’s diuretic action, which targets fluid reduction, evidenced by weight loss. Assuming pain reduction is an indicator risks missing fluid status changes, critical to prevent in ensuring accurate assessment of furosemide’s effectiveness in fluid volume excess treatment.
Choice C reason: Decreased inflammation is not a furosemide effect; it promotes diuresis, reducing fluid, shown by weight loss. Assuming inflammation reduction is relevant risks misjudging medication efficacy, potentially overlooking fluid overload signs, critical to avoid in managing fluid volume excess with diuretic therapy.
Choice D reason: Weight loss indicates furosemide’s effectiveness, as it reduces fluid volume excess through diuresis, decreasing edema and body weight. This is critical for assessing therapeutic response, ensuring fluid balance, preventing complications like heart failure, and guiding further treatment in clients with fluid overload.
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