A nurse is caring for an adult client who has been placed in physical restraints due to aggressive behavior. Which of the following actions should the nurse take?
Ask the provider to renew the prescription every 8 hr.
Have a staff member check on the client every 30 min.
Assess the client's need for toileting every 15 min.
Offer hydration and nutrition to the client every 2 hr.
The Correct Answer is D
A. The provider must renew the prescription for restraints every 4 hours for adults, not every 8 hours.
B. A staff member should check on the client every 15 minutes, not every 30 minutes, to ensure safety.
C. The client should be assessed for toileting needs every 2 hours, not every 15 minutes.
D. Offering hydration and nutrition every 2 hours is appropriate to maintain the client’s basic needs while in restraints.
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Related Questions
Correct Answer is D
Explanation
A. The provider must renew the prescription for restraints every 4 hours for adults, not every 8 hours.
B. A staff member should check on the client every 15 minutes, not every 30 minutes, to ensure safety.
C. The client should be assessed for toileting needs every 2 hours, not every 15 minutes.
D. Offering hydration and nutrition every 2 hours is appropriate to maintain the client’s basic needs while in restraints.
Correct Answer is C
Explanation
A. Soy protein is not known to interact adversely with fluoxetine.
B. Echinacea is not known to interact adversely with fluoxetine.
C. St. John's wort is known to interact adversely with fluoxetine by increasing serotonin levels, which can lead to serotonin syndrome, a potentially life-threatening condition characterized by symptoms such as confusion, agitation, rapid heart rate, and high blood pressure.
D. Ginkgo biloba is not known to interact adversely with fluoxetine.
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