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 B

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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is A

Explanation

A. Veracity involves providing accurate and truthful information to the client. By reinforcing information about potential adverse effects of a medication, the nurse ensures that the client is fully informed. This aligns with the principle of veracity because it involves transparency and honesty in discussing the potential risks associated with treatment.
B. Respecting the client's autonomy and right to make decisions about their treatment plan relates more to the ethical principle of autonomy rather than veracity. While respecting autonomy is essential, it doesn't directly address truthfulness or honesty in communication.
C. Encouraging a client to participate in a daily exercise program supports their physical well-being and can be beneficial for their recovery. However, it doesn't specifically relate to the ethical principle of veracity, which focuses on truthful communication.
D. Confidentiality is another ethical principle that pertains to protecting the client's privacy and maintaining confidentiality of their health information. While important, it doesn't directly relate to veracity, which is about honesty and truthfulness in communication with the client.

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.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

A nurse is caring for a client who is receiving acute care for the treatment of a substance use disorder. With which of the following actions is the nurse demonstrating the ethical principle of veracity?

Correct Answer is A

Explanation

A nurse is collecting data from a client who is taking lithium. Which of the following findings should the nurse identify as early manifestations of lithium toxicity? (Select all that apply.)

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

Explanation

A nurse is preparing to administer disulfiram 375 mg PO once daily. Available is disulfiram 250 mg tablets. How many tablets should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

A client is becoming increasingly agitated, anxious, and tense. The nurse notes a clenched jaw and a change in the pitch of the client's voice. Which of the following interventions should the nurse implement first?

A nurse is reinforcing teaching with a newly licensed nurse about the Patient Self-Determination Act (PSDA). Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

A nurse is assisting with teaching a group of older adult clients about behavioral expectations. Which of the following actions should the nurse take to help eliminate barriers to learning?

A nurse is obtaining a health history from a client who reports a recent suicide attempt. Which of the following responses should the nurse make?

A nurse is collecting data from a client who experienced physical abuse as a child. Which of the following findings should the nurse identify as a risk factor for the client to become a perpetrator of child abuse?

A nurse is participating in a community program about eating disorders. Which of the following information about bulimia nervosa should the nurse include in the presentation?

A nurse is caring for a client who is receiving treatment for alcohol detoxification. Which of the following medications should the nurse expect to administer during this phase of the client's care?