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 D
Explanation
Alprazolam is a benzodiazepine that can provide rapid relief of anxiety symptoms during a panic attack. Atomoxetine is a selective norepinephrine reuptake inhibitor that is used to treat attention-deficit/hyperactivity disorder, not anxiety disorders. Journaling and watching television are not appropriate interventions during an acute panic attack, as they do not address the client's physiological and psychological needs.
Correct Answer is B
Explanation
The nurse should make safety a priority and assess the client's risk for suicide first, before exploring other aspects of the client's stress level. The client's statement indicates hopelessness and despair, which are warning signs of suicidal ideation.
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