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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Speaking in rhyming sentences can be a manifestation of mania but may not necessarily require immediate reporting unless it escalates to disruptive or harmful behavior.
B. Making inappropriate sexual comments can indicate impulsivity and lack of social boundaries. It does not however precede managing the risk of hypoglycemia.
C. Poor hygiene, such as not bathing, is common in mania due to increased energy and decreased need for sleep, but it may not require immediate reporting unless it poses a significant risk to the client's health.
D. Decreased appetite and irregular eating patterns are common during mania due to increased activity levels. Eating twice in teh past is not sufficient to meet energy requirements and the client might be at risk of hypoglycemia.
Correct Answer is A
Explanation
A. This response directly addresses the potential for self-harm, which is a critical concern when a client expresses hopelessness. It is an open-ended question that invites the client to discuss their feelings and provides the nurse with information to assess the client's safety.
B. Asking the client a why question may not be alright and this may make them to be guarded.
C. This response may come off as dismissive and lacks empathy towards the client's feelings.
D. Suggesting medication without further assessment is premature and may not address the root cause of the client's statement.
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