A nurse is caring for a client who is combative and requires wrist restraints. Which of the following actions should the nurse take?

Use a quick-release tie to restrain the client.

Renew the restraint prescription every 48 hr.

Attach the restraints to the side rail of the client's bed.

Maintain 1 fingerbreadth between the restraint and the client's skin.

Answer and Explanation

The Correct Answer is A

Choice A reason: Using a quick-release tie for restraints ensures that the nurse can quickly and easily release the client in case of an emergency. Quick-release ties are designed to provide safety and convenience, allowing healthcare providers to promptly respond to the client's needs without compromising safety. This method reduces the risk of injury to both the client and the healthcare team.

Choice B reason: Restraint prescriptions typically need to be renewed more frequently than every 48 hours, often within 24 hours. The exact duration depends on the facility's policy and regulatory guidelines. Regular assessment of the need for restraints and timely renewal of the prescription ensure that restraints are used appropriately and only as long as necessary.

Choice C reason: Attaching restraints to the side rail of the client's bed is unsafe and inappropriate. Restraints should be attached to a non-movable part of the bed frame to prevent the client from injuring themselves if the side rail is moved. Securing restraints to a stable part of the bed ensures better control and reduces the risk of harm.

Choice D reason: While maintaining some space between the restraint and the client's skin is important to prevent circulation issues, the guideline typically suggests maintaining two fingers' breadth between the restraint and the client's skin, not one. This ensures adequate circulation and reduces the risk of injury or skin breakdown.

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Correct Answer is B

Explanation

Choice A reason: Lead paint exposure is associated with various health issues, particularly in children, but it is not a recognized risk factor for schizophrenia. Lead poisoning can cause cognitive and behavioral problems, but it does not directly increase the risk of developing schizophrenia.

Choice B reason: Having a family member, especially a twin sibling, with schizophrenia significantly increases the risk of developing the condition. Genetics play a crucial role in the development of schizophrenia, and individuals with a first-degree relative who has schizophrenia are at a higher risk of developing the disorder.

Choice C reason: Opioid dependence is associated with various mental health issues, including depression and anxiety, but it is not a direct risk factor for schizophrenia. Substance abuse can exacerbate existing mental health conditions, but it does not inherently cause schizophrenia.

Choice D reason: While maternal tobacco use during pregnancy is linked to various adverse outcomes, including low birth weight and developmental issues, it is not specifically identified as a risk factor for schizophrenia. The relationship between prenatal tobacco exposure and schizophrenia is not well-established.

A. "You have the right to refuse medications prescribed during your stay." B. "Your admission status allows you to leave the facility at any time." C. "Your health care team will review your admission status in 90 days." D. "You will automatically have a legal guardian appointed during this admission." E. The correct answer is: a) "You have the right to refuse medications prescribed during your stay."

Correct Answer is A

Explanation

Choice A reason: Clients who are involuntarily admitted to a psychiatric facility retain certain rights, including the right to refuse medications. This is an important part of patient autonomy and informed consent. Even though the client is involuntarily admitted, they must still be provided with information about their treatment options and have the right to make decisions about their medications unless there is a court order stating otherwise.

Choice B reason: This statement is incorrect because involuntary admission means that the client cannot leave the facility at any time. Involuntary admission is typically initiated because the client is unable to meet their own physical needs or poses a danger to themselves or others. Therefore, their ability to leave the facility is restricted until their condition improves or their admission status is reviewed and changed.

Choice C reason: This statement is misleading because the review of admission status for involuntary patients usually occurs much sooner than 90 days. Legal requirements and procedures for reviewing involuntary admission status vary by jurisdiction, but typically, initial reviews occur within a few days to weeks to ensure that the client's rights are protected and that continued hospitalization is necessary.

Choice D reason: This statement is incorrect. Involuntary admission does not automatically result in the appointment of a legal guardian. The process of appointing a legal guardian is separate and involves a legal proceeding where a court determines the need for guardianship. The involuntary admission process is primarily focused on the immediate care and safety of the client.

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A nurse is caring for a client who is combative and requires wrist restraints. Which of the following actions should the nurse take?

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