A nurse is caring for a school-age child who has conduct disorder and requires wrist restraints. Which of the following actions should the nurse take?

Monitor the child's vital signs every 15 min.

Obtain a prescription for the restraints within 2 hr of initiating them.

Have the child perform range-of-motion exercises every 3 hr.

Ensure three fingers will fit between the child's wrist and the restraint.

Answer and Explanation

The Correct Answer is A

a. This option is most appropriate in the context provided, as frequent monitoring is essential for a child in restraints to ensure their safety and well-being.

b. Obtain a prescription for the restraints within 2 hr of initiating them. - This is incorrect because the standard requirement is to obtain a prescription within 1 hour of initiating the restraints, not 2 hours.

c. While range-of-motion exercises are important, they are typically recommended every 2 hours to prevent complications like contractures.

d. The correct procedure is usually to ensure that two fingers can fit between the wrist and the restraint to ensure it's not too tight or too loose.

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Correct Answer is B

Explanation

Choice A rationale:

Documenting the client's behavior every 15 minutes is a valid nursing action when a client is placed in seclusion. However, it is not the most critical step to take in this situation. The safety and well-being of the client and staff are paramount, and obtaining the provider's prescription is more crucial.

Choice B rationale:

The correct choice. Obtaining the provider's prescription within 60 minutes is essential when a client is placed in seclusion. Seclusion is an intervention that restricts the client's freedom, and it should only be done under the supervision of a licensed healthcare provider. The nurse must obtain a prescription for this intervention as soon as possible to ensure that the client's rights and safety are respected.

Choice C rationale:

Offering the client food and fluids every 2 hours is a valid nursing action in a seclusion situation. However, it is not the most immediate priority. Obtaining the provider's prescription takes precedence to ensure the appropriateness of the intervention.

Choice D rationale:

Monitoring the client's vital signs every 4 hours is an important nursing action, but it is not the primary step to take immediately after placing a client in seclusion. Obtaining the provider's prescription is more urgent to ensure the legality and appropriateness of the intervention.

A. A client who has moderate-stage Alzheimer's disease. B. A client who has schizotypal personality disorder. C. A client who has a history of alcohol use disorder. D. A client who has a history of dependent personality disorder.

Correct Answer is A

No explanation

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A nurse is caring for a school-age child who has conduct disorder and requires wrist restraints. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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