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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale
While voice tremors can be a symptom of anxiety, they are not specifically associated with panic level anxiety. Voice tremors could be due to a variety of factors, including nervousness, fear, or certain medical conditions.
Choice B rationale
Shakiness can be a symptom of anxiety, but it is not specific to panic level anxiety. It could be a physical response to fear, stress, or even low blood sugar.
Choice C rationale
Depersonalization, a feeling of being detached or disconnected from oneself, is a common symptom of panic level anxiety. Individuals may feel as if they are observing themselves from an outside perspective.
Choice D rationale

Poor concentration can be a symptom of many mental health conditions, including anxiety. However, it is not specific to panic level anxiety and can be influenced by a variety of factors, such as stress, lack of sleep, or certain medications.

A. Be credible, collaborative, and consistent B. Be transparent, honest, and polite C. Be transparent, collaborative, and consistent D. Be honest, caring, and consistent

Correct Answer is C

Explanation

Choice A rationale

Being credible, collaborative, and consistent are important qualities for a nurse, but they do not specifically address the ethical and empathetic aspects of nursing care during a pandemic.
Choice B rationale
Being transparent and honest are important, but politeness does not necessarily equate to empathy. Furthermore, this choice does not address the collaborative aspect of nursing care, which is crucial during a pandemic.
Choice C rationale
Being transparent, collaborative, and consistent are all important behaviors for providing ethical and empathetic nursing care during a pandemic. Transparency ensures that patients and their families are fully informed about their care, collaboration ensures that all members of the healthcare team are working together for the benefit of the patient, and consistency ensures that care is reliable and dependable.
Choice D rationale
While honesty and caring are important, consistency alone does not necessarily equate to ethical and empathetic care. This choice does not address the importance of transparency and collaboration in nursing care during a pandemic.

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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?

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Naxlex Comprehensive Predictor Exams

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