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 B

Explanation

A. This response could come across as blaming or judgmental. It implies that the client made a mistake by not seeking help, which can exacerbate feelings of guilt or shame. It does not promote an open dialogue or supportive environment.
B. This response demonstrates empathy and a willingness to understand the client's emotional state leading up to the suicide attempt. It encourages open communication about the client's feelings and experiences, which is crucial for assessment and intervention planning.
C. This response suggests that the nurse is making assumptions about the client's emotions without allowing the client to express themselves fully. While guilt may be a common emotion after a suicide attempt, it's important for the nurse to first listen to the client's own description of their feelings.
D. This response minimizes the seriousness of the client's experience and emotions. It may invalidate the client's feelings of distress or despair that led to the suicide attempt. Such a response does not acknowledge the gravity of the situation or provide the necessary support.

A. Decrease the client's dietary potassium. B. Increase the client's daily caloric intake. C. Monitor the client for hypoglycemia. D. Administer the medication with meals.

Correct Answer is D

Explanation

A. Lithium can affect sodium and potassium balance in the body, but it does not specifically require a decrease in dietary potassium. Instead, sodium intake should be kept consistent because lithium excretion is influenced by sodium levels. Therefore, decreasing dietary potassium is not a recommended intervention.
B. Lithium can sometimes cause weight gain as a side effect. Increasing daily caloric intake is not a standard intervention when starting lithium. Clients should be encouraged to maintain a balanced diet and regular exercise regimen to manage potential weight changes.

C. Hypoglycemia is not a common side effect of lithium. Therefore, monitoring for hypoglycemia is not necessary when a client is taking lithium.
D. Administering lithium with meals can help reduce gastrointestinal side effects, such as nausea and upset stomach, which are common when starting the medication. It also helps with consistent absorption and reduces the peak serum concentration of lithium, which can minimize side effects and stabilize blood levels.

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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 B

Explanation

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Correct Answer is D

Explanation

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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?