A nurse is collecting data from a client who has a wrist restraint in place. Which of the following findings should the nurse identify as an indication of a complication of the restraint?
The client has full range of motion in her wrist.
The client is attempting to remove the restraint.
The client's hand is cool and pale.
The client has a capillary refill of 1 second.
The Correct Answer is C
Choice A reason: Full range of motion indicates that circulation and mobility are intact. This is not a complication.
Choice B reason: Attempting to remove the restraint shows discomfort or resistance but does not indicate a complication.
Choice C reason: A cool, pale hand suggests impaired circulation due to the restraint. This is a serious complication that requires immediate intervention to prevent tissue damage.
Choice D reason: A capillary refill of 1 second is normal and indicates adequate perfusion. This is not a complication.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Eating half of meals indicates reduced intake but is not immediately dangerous. It requires monitoring but is not the priority.
Choice B reason: Diminished facial affect is a negative symptom of schizophrenia. While important to document, it does not pose immediate risk.
Choice C reason: Decreased energy level is nonspecific and could be related to medication or illness. It is not urgent compared to bizarre behaviors.
Choice D reason: Bizarre behaviors are a positive symptom that may indicate worsening psychosis. They can pose safety risks to the client or others, making them the priority to report.
Correct Answer is A
Explanation
Choice A reason: Asking if the client has a plan to commit suicide is the priority intervention. It directly assesses the level of risk and helps determine the immediacy of danger. Suicide risk assessment is essential in borderline personality disorder, where impulsivity and self-harm are common.
Choice B reason: Assuming manipulation dismisses the seriousness of suicidal ideation. Even if manipulation is suspected, all suicidal statements must be taken seriously to ensure safety.
Choice C reason: Allowing the client to rest does not address the risk of suicide. Safety assessment must occur before any other intervention.
Choice D reason: Notifying family may be supportive but is not the immediate priority. The nurse must first assess the client’s risk and ensure safety before involving others.
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