A nurse is caring for a client who is in physical restraints after demonstrating aggressive behavior. Which of the following criteria must be met before the nurse can remove the restraints?
The client must be calm and cooperative.
The provider who prescribed the restraints must be present to assess the client before the restraints can be removed.
The client must verbalize remorse for their behavior.
The client only verbalizes anger toward the staff.
The Correct Answer is A
Choice A rationale
The client must be calm and cooperative. This is the most important criterion for removing physical restraints. Restraints are used to prevent patients from causing harm to themselves or others. Once the patient is calm and cooperative, it indicates that the risk of harm has decreased. The goal is always to use the least restrictive measures and to remove restraints as soon as possible.
Choice B rationale
The provider who prescribed the restraints must be present to assess the client before the restraints can be removed. This is not necessarily true. While a provider’s order is required to initiate restraints, the decision to remove them can often be made by the nurse based on their assessment of the patient.
Choice C rationale
The client must verbalize remorse for their behavior. This is not a requirement for removing restraints. The primary concern is the safety of the patient and others, not whether the patient expresses remorse.
Choice D rationale
The client only verbalizes anger toward the staff. If the client is still expressing anger, it may not be safe to remove the restraints. However, verbalizing anger alone is not a sufficient reason to keep a patient in restraints.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Clean drinking water is indeed crucial for preventing many diseases, especially those transmitted through the fecal-oral route or waterborne diseases such as cholera, typhoid, and hepatitis A1. However, it is not specifically targeted at diseases that are transmitted directly from person to person. Directly transmitted diseases are often spread through direct contact, such as person-to-person contact or droplet spread. Therefore, while clean drinking water is an essential aspect of public health, it is not the most effective method for preventing diseases that are transmitted directly.
Choice B rationale
Pest control is an important measure for preventing diseases transmitted by vectors, such as mosquitoes, ticks, and fleas. Diseases like malaria, dengue, Lyme disease, and plague are examples of vector-borne diseases. However, these diseases are not considered directly transmitted diseases. Direct transmission occurs when an infectious agent is transferred from a reservoir to a susceptible host by direct contact or droplet spread. Therefore, pest control, while important, is not the primary prevention method for diseases that are transmitted directly.
Choice C rationale
Isolation is one of the most effective methods for preventing the spread of directly transmitted diseases. When a person is isolated, they are separated from others to prevent the spread of communicable diseases. Isolation is used in healthcare settings to prevent the spread of infectious diseases that can be transmitted directly from person to person, such as tuberculosis, influenza, and COVID-191. Therefore, isolation is a key prevention method for diseases that are transmitted directly.
Choice D rationale
Proper sanitation, like clean drinking water, is crucial for preventing many diseases, particularly those transmitted through the fecal-oral route. Proper sanitation involves safely managing human waste and maintaining hygienic conditions through services such as garbage collection and wastewater disposal. While it is an essential aspect of public health, proper sanitation is not the most effective method for preventing diseases that are transmitted directly from person to person.
Correct Answer is D
Explanation
This scenario requires applying knowledge of mental health resilience and protective factors. To answer, one must distinguish between risk factors, such as maternal age or family instability, and positive childhood experiences, like supportive adult relationships, which mitigate the impact of anxiety disorders.
Choice A rationale: Maternal age at birth is often considered a social determinant of health rather than a protective factor. Adolescents born to teenage parents may face higher socio-economic challenges, which are generally categorized as potential risk factors for stress.
Choice B rationale: Having parents in the military is a demographic characteristic that often involves unique stressors. While military families can be supportive, the career itself is not inherently a protective childhood experience without further context regarding family dynamics.
Choice C rationale: Moving frequently, or high residential mobility, is typically viewed as a risk factor for adolescent anxiety. Frequent moves can disrupt social support networks, peer relationships, and educational consistency, potentially exacerbating symptoms of an anxiety disorder.
Choice D rationale: A supportive relationship with a non-parental adult, such as a teacher, is a significant protective factor. Positive childhood experiences involving being heard and supported build resilience and provide an emotional buffer against the effects of anxiety.
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