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 A

Explanation

A. Unlike anorexia nervosa, where individuals typically appear underweight, people with bulimia nervosa often maintain a body weight within the normal or even overweight range. This can make it challenging to identify based on physical appearance alone, as individuals may hide their binge-eating and purging behaviors.
B. Individuals with bulimia nervosa often engage in episodes of binge-eating, during which they consume large amounts of food in a short period and feel a loss of control over their eating. This is followed by compensatory behaviors such as self-induced vomiting, misuse of laxatives or diuretics, fasting, or excessive exercise to prevent weight gain.
C. Bulimia nervosa does not directly increase the risk of developing diabetes mellitus. However, the binge-eating episodes characteristic of bulimia can lead to metabolic disturbances and insulin resistance over time. This can potentially increase the risk of developing type 2 diabetes in individuals who are predisposed or have other risk factors.
D. While self-induced vomiting is a common purging method in bulimia nervosa, there are other ways individuals may attempt to compensate for binge-eating episodes, such as excessive exercise, fasting, or misuse of laxatives or diuretics. The key diagnostic criteria for bulimia nervosa include recurrent episodes of binge-eating and inappropriate compensatory behaviors to prevent weight gain.

A. Incoordination B. Polyuria C. Nausea D. Convulsions E. Confusion

Correct Answer is ["A","C","E"]

Explanation

A. Incoordination, such as clumsiness or difficulty walking, can be an early sign of lithium toxicity. It reflects the neurological effects of elevated lithium levels on motor coordination.
B. Polyuria (excessive urination) is a common late symptom of lithium toxicity. Lithium interferes with the kidney's ability to concentrate urine, leading to increased urine output.
C. Nausea is a gastrointestinal symptom that can occur in the early stages of lithium toxicity. It is often accompanied by other gastrointestinal disturbances such as vomiting and diarrhea.
D. Convulsions (seizures) are not typically considered early manifestations of lithium toxicity but rather indicate severe toxicity. Seizures can occur at higher levels of lithium toxicity and require immediate medical intervention.
E. Confusion is another early sign of lithium toxicity. It reflects the impact of elevated lithium levels on the central nervous system, leading to cognitive impairment and altered mental status.

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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 A

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Correct Answer is ["A","C","E"]

Explanation

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