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 D

Explanation

Choice A rationale
A child expressing that their parent is mean because they can’t have a dog does not constitute an adverse childhood experience (ACE). This is a common situation where a child might be upset due to not getting what they want, but it does not indicate any form of abuse, neglect, or household dysfunction that are typically associated with ACEs.
Choice B rationale
Failing an algebra test is a part of the academic challenges that students face and does not constitute an ACE. While it can be a source of stress for the child, it is not an indicator of abuse, neglect, or household dysfunction.

Choice C rationale
Forgetting lunch at home is a common occurrence among children and does not indicate an ACE. It could be a simple oversight or a result of a chaotic morning routine. It does not suggest abuse, neglect, or household dysfunction.
Choice D rationale
Having a parent who is in prison is considered an ACE. This situation falls under the category of household dysfunction. The incarceration of a parent can lead to a loss of financial stability, emotional support, and the social stigma associated with it can lead to feelings of shame and isolation for the child.

A. Post-traumatic play B. Men formation C. Depersonalization D. Time skewing .

Correct Answer is A

Explanation

Choice A rationale
Post-traumatic play is a way for children to re-enact the traumatic event, and it is a common reaction among children who have experienced trauma. The child in the question mimicking shooting a gun with their hand whenever someone enters the room or tries to interact with them could be an example of this.
Choice B rationale
There is no recognized PTSD symptom or manifestation known as “Men formation.”.
Choice C rationale

Depersonalization involves experiencing a sense of being detached or disconnected from oneself, observing oneself from an outside perspective, or experiencing a sense of unreality. This does not seem to apply to the child’s behavior in the question.
Choice D rationale
Time skewing refers to a shift in the perception of time, which is not evident in the child’s behavior in the question.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is screening children and adolescents for exposure to adverse childhood experiences (ACEs). Which of the following clients is considered to have experienced an ACE?

Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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