A nurse is caring for a client who was placed in four-point restraints by the nursing staff following an episode of violent behavior. Which of the following actions should the nurse take?

Keep staff interactions with the client to a minimum.

Provide range-of-motion exercises to all extremities every 2 hr.

Request the provider renew the prescription in 24 hr.

Document the client's behavior in the medical record every 1 hr.

Answer and Explanation

The Correct Answer is C

A.   Keeping staff interactions to a minimum may not be beneficial as the client might require regular monitoring and interaction to assess their condition and needs.
B.   When a client is restrained, it's crucial to prevent complications such as muscle stiffness and joint contractures. Range-of-motion exercises help maintain circulation, prevent discomfort, and preserve joint mobility. However, this is not the most important action.
C.   Restraints should only be used when absolutely necessary and prescribed by a provider. In many jurisdictions and healthcare facilities, the use of restraints requires a specific order that must be renewed periodically (often every 24 hours). This practice ensures that the need for restraints is continually reassessed and that they are not used longer than necessary.
D.   Accurate and frequent documentation is essential when a client is restrained. Documentation should include the client's behavior, physical assessments, interventions provided (such as medication administration or hygiene care), and responses to interventions. However, this is not the most important action.

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Correct Answer is C

Explanation

A. A submissive personality alone is less likely to be a direct risk factor for becoming a perpetrator of child abuse. Individuals with a submissive personality tend to avoid confrontation and conflict rather than engage in aggressive or abusive behaviors towards others.
B. Being involved in community activities is generally a positive factor that promotes social engagement, support networks, and a sense of belonging. It does not inherently contribute to an increased risk of becoming a perpetrator of child abuse.
C. Low tolerance for frustration can be a risk factor for potential aggressive or impulsive behaviors. When individuals have difficulty managing frustration, they may be more prone to react impulsively or aggressively towards others, including children.

D. The absence of impulsive behaviors typically indicates better impulse control and decision-making abilities. Individuals who can regulate their impulses are less likely to engage in spontaneous or aggressive actions, including perpetrating child abuse.

A. Buprenorphine B. Diazepam C. Varenicline D. Rimonabant

Correct Answer is B

Explanation

A. Buprenorphine is primarily used for the treatment of opioid dependence, not alcohol detoxification. It is a partial opioid agonist and can precipitate withdrawal symptoms in individuals dependent on opioids. Therefore, it is not appropriate for alcohol detoxification and would not typically be administered in this context.
B. Diazepam belongs to the benzodiazepine class of medications and is commonly used during alcohol detoxification. Benzodiazepines help manage symptoms of alcohol withdrawal, including anxiety, tremors, agitation, and seizures. They work by enhancing the effects of gamma-aminobutyric acid (GABA), which is an inhibitory neurotransmitter in the brain. Diazepam has a longer duration of action and is preferred in managing alcohol withdrawal due to its smoother pharmacokinetic profile compared to shorter-acting benzodiazepines.
C. Varenicline is a medication used for smoking cessation. It works by partially activating nicotine receptors in the brain, reducing the pleasurable effects of smoking and decreasing withdrawal symptoms. It is not indicated for alcohol detoxification and would not be used in this context.
D. Rimonabant is a cannabinoid receptor antagonist that was once used for weight loss but has been withdrawn from the market due to psychiatric side effects, including depression and anxiety. It is not indicated for alcohol detoxification and would not be administered in this context.

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A nurse is caring for a client who was placed in four-point restraints by the nursing staff following an episode of violent behavior. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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