A nurse is caring for a client who has physical restraints applied. The nurse determines that the restraints should be removed when which of the following occurs?
The client states that he will harm himself unless the restraints are removed.
The client demonstrates that he is oriented to person, place, and time.
The client is able to follow commands.
The client refuses to take his medication unless he is released.
The Correct Answer is B
A. The client states that he will harm himself unless the restraints are removed.
This statement indicates a clear risk, but merely stating a desire for restraint removal is not sufficient reason to remove restraints. It's essential to assess the patient comprehensively and make the decision based on their current state and safety concerns.
B. The client demonstrates that he is oriented to person, place, and time.
When a restrained patient shows orientation to person (knows who they are and who others are), place (knows where they are), and time (knows the current date and time), it suggests they are aware of their surroundings and can make rational decisions. This orientation indicates a level of awareness that might justify removing the restraints.
C. The client is able to follow commands.
While following commands is an important aspect, it alone might not be enough to guarantee the patient's overall awareness of their situation and safety. A comprehensive assessment, including orientation and ability to follow commands, is necessary.
D. The client refuses to take his medication unless he is released.
Medication refusal alone may not be a sufficient reason to remove restraints, especially if the patient is not demonstrating an understanding of their situation or if releasing the restraints could pose a risk to the patient or others.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Buprenorphine:
Buprenorphine is a medication used in the treatment of opioid dependence. It acts on the same receptors in the brain as opioids, helping to reduce cravings and withdrawal symptoms in individuals recovering from opioid addiction. It is not typically used for alcohol withdrawal.
B. Naltrexone:
Naltrexone is an opioid receptor antagonist used in the treatment of alcohol dependence. It works by blocking the effects of endorphins, the body's natural opioids. In the context of alcohol dependence, it reduces the rewarding effects of alcohol and decreases the craving for alcohol. Naltrexone can be prescribed for individuals experiencing acute manifestations of alcohol withdrawal as part of a comprehensive treatment plan.
C. Disulfiram:
Disulfiram is a medication that causes unpleasant symptoms (such as nausea, vomiting, and flushing) when alcohol is consumed. It works as a deterrent, discouraging individuals from drinking alcohol by creating a negative reaction. Disulfiram is used as a part of comprehensive alcohol treatment programs to help maintain abstinence. It is not typically used for acute alcohol withdrawal symptoms.
D. Bupropion:
Bupropion is an antidepressant medication that is also used to aid smoking cessation. It helps reduce withdrawal symptoms and the urge to smoke. While it is not used specifically for alcohol withdrawal, individuals with alcohol dependence often have higher rates of tobacco use. Bupropion might be prescribed to address both smoking cessation and depressive symptoms in individuals with alcohol dependence, but it does not directly address alcohol withdrawal.
Correct Answer is D
Explanation
A. Increased time sleeping:
Increased time sleeping alone is not a specific or direct indicator of PTSD. However, changes in sleep patterns are common in individuals with PTSD, with symptoms like nightmares, insomnia, and disturbances in sleep. These disturbances can lead to increased time in bed, but this alone is not a definitive sign of PTSD.
B. Inability to express empathy:
Inability to express empathy is a complex issue and could be related to various emotional or psychological factors. While people with PTSD can experience difficulties in interpersonal relationships, including issues with empathy, this alone is not a specific indicator of the disorder. PTSD primarily involves symptoms related to re-experiencing trauma, avoidance, negative mood changes, and arousal symptoms.
C. Auditory hallucinations:
Auditory hallucinations, which involve hearing voices or sounds that others do not, are not typically associated with PTSD. This symptom is more commonly linked to conditions like schizophrenia or other psychotic disorders, but it is not specific to PTSD.
D. Difficulty concentrating:
Difficulty concentrating is a common and well-recognized symptom of PTSD. Individuals with PTSD often struggle with focus, memory, and attention due to the intrusion of traumatic thoughts and memories. This symptom can significantly impact their daily functioning and is one of the hallmark features of the disorder.
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