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
The correct answer is Choice C
Choice A rationale: A reluctance to leave the house for over a year suggests a struggle with grief and possibly depression but does not specifically indicate traumatic grief. It reflects difficulty in moving forward but lacks the intense guilt associated with traumatic grief.
Choice B rationale: Inability to cry due to a perceived need to be strong reflects emotional suppression and societal expectations. It does not directly point to traumatic grief, which often involves more severe symptoms like intense guilt and preoccupation with the deceased.
Choice C rationale: Feeling that one should have been killed instead of a friend indicates severe survivor guilt, a core component of traumatic grief. This statement reflects an intense emotional reaction and an inability to reconcile the loss, leading to profound distress and dysfunction.
Choice D rationale: Flashbacks and physical symptoms like a racing heart suggest post-traumatic stress disorder (PTSD) rather than traumatic grief. PTSD involves re-experiencing traumatic events, whereas traumatic grief focuses more on the loss and associated guilt
Correct Answer is B
Explanation
Choice A rationale
While it’s important for a child to be taken to the hospital if they develop difficulty breathing, this is more of a tertiary prevention strategy, as it involves managing the symptoms of an existing disease.
Choice B rationale
Testing the child to determine the cause of their illness is a form of secondary prevention. By identifying whether the child has SARS-CoV-2, appropriate measures can be taken to treat the illness and prevent further spread.
Choice C rationale
Immunization is a form of primary prevention, as it aims to prevent the disease from occurring in the first place.
Choice D rationale
Wearing a mask can help prevent the spread of SARS-CoV-2, but it is more of a primary prevention strategy, as it aims to prevent exposure to the virus.
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