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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is ["90"]
Explanation
To find out how many mL the nurse should administer for the total daily dose, we need to calculate the total daily dose and then convert it to mL using the available concentration.
The client is prescribed hydroxyzine 60 mg PO every 8 hours. To find the total daily dose, we can first calculate the dose per day and then convert it to mL.
Dose per day = Dose per dose interval x Number of doses per day
Dose per day = 60 mg x 3 (every 8 hours)
Dose per day = 180 mg per day
Now, we need to convert this dose to mL using the available concentration:
Concentration: 10 mg/5 mL
To find out how many mL for 180 mg, we can set up a proportion:
(10 mg / 5 mL) = (180 mg / x mL)
Cross-multiply:
10 mg * x mL = 5 mL * 180 mg
Now, solve for x (the number of mL):
x mL = (5 mL * 180 mg) / 10 mg
x mL = 900 mL / 10 mg
x mL = 90 mL
So, the nurse should administer 90 mL for the total daily dose.
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