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 symptoms described by the patient are indicative of Generalized Anxiety Disorder (GAD). GAD is characterized by excessive anxiety and worry about a number of events or activities.
The worry is out of proportion to the actual circumstance and is difficult to control.
Choice B rationale
Panic disorder is characterized by recurrent unexpected panic attacks, which are abrupt surges of intense fear or discomfort that reach a peak within minutes.
Choice C rationale
Agoraphobia involves fear and avoidance of situations where escape might be difficult or help might not be available in the event of developing panic-like symptoms.
Choice D rationale
Separation anxiety disorder is characterized by excessive fear or anxiety about separation from those to whom the individual is attached.
Correct Answer is B
Explanation
Choice A rationale
Using EPA registered insect repellants is a form of primary prevention, as it aims to prevent tick bites, which are the primary mode of transmission for Lyme disease.
Choice B rationale
Checking your clothing and body for ticks after being outdoors is a form of secondary prevention. If a tick is found and removed before it has had a chance to transmit the bacteria that cause Lyme disease, this can prevent the disease from occurring.
Choice C rationale
Wearing long-sleeved shirts and pants while outdoors is another form of primary prevention, as it can help prevent tick bites.
Choice D rationale
Notifying your health care provider if you notice a rash (especially a bull’s-eye rash, which is a common early symptom of Lyme disease) is a form of tertiary prevention, as it involves managing the symptoms of an existing disease.
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