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 A

Explanation

A. This response acknowledges the client's feelings and validates their experience without confirming or denying the delusion.
B. This response challenges the client's belief and may cause distress or exacerbate paranoia.

C. While factually correct, this response may not address the client's underlying concerns or feelings.
D. This response may invalidate the client's experience and may not effectively address the delusional belief.

A. "I will use the coping mechanisms that helped me in the past." B. "I will rely on my partner to plan out my schedule each day." C. "I will stay in bed on days when I feel exhausted." D. "I will avoid talking about events that upset me."

Correct Answer is A

Explanation

A. This choice demonstrates an understanding of the importance of utilizing effective coping mechanisms.

B. Depending solely on a partner to plan daily activities may indicate dependence rather than self-care.
C. Remaining in bed excessively can perpetuate depressive symptoms and hinder recovery.
D. Avoiding discussing upsetting events may prevent processing emotions and hinder progress in therapy.

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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?

Nursing Test Bank

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