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 B
Explanation
Choice A rationale
Recommending the client obtain a part-time job may not be the most effective intervention for an adolescent experiencing depression due to a recent move. While employment can provide a sense of purpose and routine, it may also add additional stress and responsibilities that could potentially exacerbate the client’s depression.
Choice B rationale
Scheduling an appointment with a school-based counselor is the most appropriate intervention. School-based counselors are trained to provide emotional support and therapeutic interventions to students dealing with various issues, including depression. They can provide a safe space for the client to express their feelings and can help them develop coping strategies to manage their depression.
Choice C rationale
Arranging a visit with a neurologist is not the most appropriate first intervention. While neurologists can provide treatment for neurological conditions, they are not typically the first point of contact for managing depression.
Choice D rationale
Encouraging the client to engage in more physical activity can be beneficial as exercise has been shown to have a positive effect on mood. However, it may not be sufficient as the sole intervention for an adolescent experiencing depression
Correct Answer is A
Explanation
Choice A rationale
Paroxetine is a type of selective serotonin reuptake inhibitor (SSRI) that is commonly prescribed for the treatment of PTSD6. It works by increasing the levels of serotonin, a neurotransmitter that helps regulate mood, in the brain.
Choice B rationale
Semaglutide is a medication used to control blood sugar levels in people with type 2 diabetes. It is not typically used in the treatment of PTSD.
Choice C rationale
Tramadol is a prescription pain medication used to treat moderate to severe pain. While it can help manage physical symptoms that may accompany PTSD, it is not typically used as a primary treatment for the disorder.
Choice D rationale
Zaleplon is a medication used to treat insomnia. While it can help manage sleep disturbances that may accompany PTSD, it is not typically used as a primary treatment for the disorder.
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