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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D","E"]
Explanation
B is correct because reporting any adverse effects of the medication can help the provider adjust the dosage or prescribe a different medication if needed. Some common adverse effects of haloperidol are extrapyramidal symptoms, tardive dyskinesia, neuroleptic malignant syndrome, and anticholinergic effects.
C is correct because notifying the provider within 48 hr of manifestations of a relapse can help the client receive timely intervention and prevent further deterioration of their mental health. Some signs of a relapse are increased anxiety, paranoia, social withdrawal, insomnia, and mood swings.
D is correct because going for a walk or engaging in other physical activities can help the client cope with stress and reduce anxiety, which are common triggers for schizophrenia symptoms.
E is correct because asking a trusted person to watch for manifestations of illness can help the client gain insight into their condition and seek help when needed. A trusted person can be a family member, a friend, or a mental health professional.
A is incorrect because taking a dose of the medication as soon as delusions or hallucinations begin is not an effective strategy for relapse prevention. The client should take their medication as prescribed by their provider and not adjust the dosage on their own.
F is incorrect because limiting alcohol consumption to no more than two drinks per week is not sufficient for relapse prevention. Alcohol can interact with haloperidol and increase its sedative effects, impairing the client's judgment and cognition. Alcohol can also worsen schizophrenia symptoms and interfere with recovery. The client should avoid alcohol altogether or consult with their provider before consuming any alcohol.
Correct Answer is B
Explanation
The priority for the nurse is to assess the client's safety and risk of self-harm or suicide, which may increase during a situational crisis. The other questions are also important to explore, but they are not as urgent as assessing for suicidal ideation or intent.
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