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 A
Explanation
Choice A rationale
The statement that the milieu consists of the physical and psychosocial environmental factors indicates an understanding of therapeutic milieu. The therapeutic milieu refers to the structured and safe environment that is created in a mental health setting to promote therapeutic interaction and healing.
Choice B rationale
The positioning of chairs around the perimeter of the day room does not necessarily indicate an understanding of therapeutic milieu. While the physical arrangement of the environment can contribute to the therapeutic milieu, it is not the defining aspect.
Choice C rationale
The statement that therapeutic milieu requires unstructured programming, allowing clients to focus on their interests, does not accurately reflect the concept of therapeutic milieu. While client interests are important, therapeutic milieu often involves structured activities designed to promote therapeutic interaction and healing.
Choice D rationale
The statement that clients can keep any personal items in their rooms does not necessarily indicate an understanding of therapeutic milieu. While personal items can contribute to a sense of comfort and safety, therapeutic milieu involves more than just the physical environment.
Correct Answer is D
Explanation
Choice A rationale
Maintaining an upright posture during a client interview is generally seen as a sign of attentiveness and professionalism. It shows that the nurse is focused on the conversation and respects the client’s concerns.
Choice B rationale
Sitting at a slight angle across from the clients is a part of active listening and is considered a positive nonverbal communication technique. It allows the nurse to maintain eye contact and observe the client’s nonverbal cues.
Choice C rationale
Maintaining eye contact throughout the interview is a positive nonverbal communication technique that shows the nurse is paying attention and is interested in what the client is saying. However, it’s important to note that in some cultures, direct eye contact may be considered disrespectful or intrusive.
Choice D rationale
Leaning away from the client throughout the interview can be perceived as a sign of disinterest or discomfort. It may give the impression that the nurse is not engaged in the conversation or is maintaining a distance from the client. This can hinder the development of a therapeutic nurse-client relationship.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
