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.
Have the child perform range-of-motion exercises every 3 hr.
Ensure three fingers will fit between the child's wrist and the restraint.
Obtain a prescription for the restraints within 2 hr of initiating them.
The Correct Answer is D
The nurse should obtain a prescription for the restraints within 2 hr of initiating them, as this is a legal requirement and ensures that the restraints are used appropriately and safely. The other options are also important, but they are not the priority action in this situation.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The rationale is that a client who is legally incompetent cannot give informed consent, and the nurse should obtain consent from the person who has the legal authority to make decisions for the client, such as a guardian or a durable power of attorney.
Correct Answer is A
Explanation
Choice A reason:
Significant weight loss in a patient with major depressive disorder is a red flag for clinicians. It can signify a high risk of complications, including malnutrition, electrolyte imbalance, and weakened immunity. In the context of depression, it may also reflect a lack of self-care or even suicidal tendencies, which require immediate attention.
Choice B reason:
While markedly neglected hygiene is concerning and indicative of a patient's inability to perform daily self-care activities, it is not typically considered an immediate life-threatening issue. However, it does warrant intervention to prevent potential secondary infections or complications.
Choice C reason:
Psychomotor retardation is a symptom that can manifest in major depressive disorder, characterized by slowed physical movements and cognitive processing. Although it impacts the quality of life and daily functioning, it is not usually a direct indicator of an acute life-threatening condition.
Choice D reason:
Poor problem-solving skills are part of the cognitive symptoms of depression, affecting a patient's ability to manage daily tasks and make decisions. While this can significantly impact a patient's life, it is not as urgent as significant weight loss, which can have immediate physical health consequences.
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