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. Tinnitus, or ringing in the ears, is not a common side effect of haloperidol. Therefore, this statement does not indicate an accurate understanding of the medication's potential side effects.
B. Urinary incontinence is also not typically associated with haloperidol. Therefore, this statement does not reflect correct knowledge about the medication.
C. Haloperidol can indeed make individuals more sensitive to sunlight, and patients are often advised to avoid prolonged exposure to the sun and to use sunscreen when outdoors.
D. Haloperidol is not associated with any form of dygeusia

A. Bradycardia B. Drowsiness C. Double vision D. Hypertension

Correct Answer is D

Explanation

A. Bradycardia (slow heart rate) is not typically associated with alcohol withdrawal. Instead, tachycardia (rapid heart rate) is more commonly observed due to the stimulant effects of alcohol withdrawal on the autonomic nervous system.
B. Drowsiness is not a common symptom of alcohol withdrawal. Instead, individuals may experience insomnia or disturbed sleep patterns as part of withdrawal symptoms.
C. Double vision (diplopia) is not a typical finding in alcohol withdrawal.
D. When a person stops or significantly decreases their alcohol intake after long-term use, the body can react with symptoms like increased blood pressure.

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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 D

Explanation

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