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.

Answer and Explanation

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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Correct Answer is C

Explanation

A. Meeting one's own needs without manipulating others may be a desirable outcome but is not specific to the core deficits of autism spectrum disorder.

B. Acknowledging that delusions are not real is more relevant to psychotic disorders rather than autism spectrum disorder.
C. Initiating social interactions with caregivers is an appropriate outcome for individuals with autism spectrum disorder, as it reflects improved social communication skills and social engagement.
D. Individuals with autism spectrum disorder may have difficulty understanding and responding to peer pressure, so changing behavior as a result of peer pressure may not be a realistic or desirable outcome.

A. Give the client atropine 30 min before the procedure. B. Witness the client's signature on the consent for the procedure. C. Check the client's condition after the procedure. D. Assist the client to ambulate for the first time following the procedure.

Correct Answer is D

Explanation

A. Administering medications, such as atropine, requires nursing judgment and assessment of the client's condition, which should not be delegated to assistive personnel.
B. Witnessing the client's signature on the consent form ensures that the client provides informed consent for the procedure and requires nursing judgment.
C. Assessing the client's condition after the procedure involves monitoring vital signs, level of consciousness, and potential adverse reactions, which require nursing assessment and judgment.
D. Assisting the client to ambulate after the procedure is a task that can be safely delegated to assistive personnel, as long as the client's condition is stable and there are no contraindications to ambulation.

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