A nurse is discussing the use of mechanical restraints with a newly licensed nurse. Which of the following situations should the nurse include as an indication for placing a client in mechanical restraints?
Self-destructive behavior despite alternative interventions
Discipline for throwing objects at staff
Punishment for verbally abusing other clients
Coercion to take prescribed medications
The Correct Answer is A
A. Self-destructive behavior despite alternative interventions: Mechanical restraints may be considered when a client poses an immediate risk of harm to themselves, and alternative interventions have been ineffective or are not feasible.
B. Discipline for throwing objects at staff: Mechanical restraints are not appropriate as a form of discipline. Restraints should only be used when there is an imminent risk of harm to the client or others.
C. Punishment for verbally abusing other clients: The use of restraints as a form of punishment is not ethical or appropriate. Restraints should be employed solely to prevent harm, not as a disciplinary measure.
D. Coercion to take prescribed medications: Coercion to take medications is not a valid reason for using mechanical restraints. Alternative approaches, such as therapeutic communication or discussing the need for medications with the client, should be explored.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Correct. Using the proportion, the correct dose of fluoxetine (Prozac) for the prescribed 60 mg is 15 mL.
B. Incorrect. This is not the correct dose. The correct dose is 15 mL, not 20 mL.
C. Incorrect. This is not the correct dose. The correct dose is 15 mL, not 25 mL.
D. Incorrect. This is not the correct dose. The correct dose is 15 mL, not 10 mL.
Correct Answer is B
Explanation
A. "The voices talk only at night when I'm trying to sleep."
This statement does not necessarily indicate a direct threat to the patient or others. It may be a manifestation of hallucination, but it doesn't explicitly pose a danger.
B. "The voices say everyone is trying to kill me."
This statement suggests paranoid delusions and a direct threat to the patient's safety. The nurse should implement safety measures to protect the patient and others from potential harm.
C. "I hear angels playing harps."
This statement describes a positive or benign hallucination, which may not require immediate safety measures. While it might be distressing for the patient, it doesn't pose an imminent danger.
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