A nurse is working with a client who becomes combative and threatens other clients and staff. Which of the following actions should the nurse take?

Stand in front of the client to block them from others in the room.

Apply restraints according to the facility's standing order.

Ensure there are enough staff members available for assistance.

Obtain a PRN prescription for restraints from the provider.

Answer and Explanation

The Correct Answer is C

Choice A reason: Standing in front risks escalation and injury; de-escalation needs space. Safety protocol prioritizes staff positioning away from a combative client’s reach.

Choice B reason: Standing orders for restraints vary; immediate application skips assessment. Ensuring staff support first allows safer, assessed intervention per guidelines.

Choice C reason: Adequate staff ensures safe de-escalation or restraint if needed. It’s the priority, reducing risk to all in a combative situation effectively.

Choice D reason: PRN restraint orders follow de-escalation attempts; staff availability precedes this. Immediate safety via numbers is critical before seeking prescriptions here.

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Correct Answer is A

Explanation

Choice A reason: Preschoolers (ages 3-5) often exhibit magical thinking, believing their actions cause events like death. This egocentric view links bad behavior to parental loss as punishment, reflecting their developmental stage where causality is self-focused, not abstract, aligning with typical grief responses in this age group scientifically.

Choice B reason: Understanding universal mortality requires abstract thinking, which develops later (around adolescence). Preschoolers lack this cognitive capacity, focusing instead on concrete, self-related explanations. This advanced comprehension is inconsistent with their developmental stage, making it an unlikely response to parental death in this age group.

Choice C reason: Recognizing permanent loss (never waking up) emerges around school age (6-12), not preschool. Younger children see death as reversible, like sleep, due to limited abstract reasoning. This understanding exceeds their developmental grasp, misaligning with typical preschool grief perceptions rooted in concrete thinking.

Choice D reason: Curiosity about funerals may occur, but it’s not a defining preschool grief trait. Their focus is more on magical thinking or separation anxiety, not procedural interest. This response, while possible, lacks the developmental specificity of self-blame, making it less consistent with scientific age-related grief patterns.

A. Place the shoulder harnesses at the level of the infant’s shoulders. B. Put a small cushion under the newborn’s head for support. C. Position the car seat at a 90-degree angle. D. Keep the airbag on if the car seat is in the front seat.

Correct Answer is A

Explanation

Choice A reason: Shoulder harnesses at shoulder level secure the infant, distributing crash forces evenly. Scientifically, this aligns with safety standards, preventing spinal injury by stabilizing the torso, a critical car seat feature per biomechanical crash studies for optimal protection.

Choice B reason: A cushion under the head risks airway obstruction or spinal misalignment in crashes. Scientifically, added padding alters manufacturer design, increasing injury risk, as car seats are engineered for direct fit without extras per safety regulations.

Choice C reason: A 90-degree angle is upright, risking airway collapse in newborns with weak necks. Scientifically, a 30-45-degree recline supports breathing and spinal alignment, making this unsafe per pediatric and crash safety evidence.

Choice D reason: Airbags in the front seat can fatally injure infants in rear-facing seats via rapid inflation. Scientifically, back-seat placement avoids this, as airbag force exceeds infant tolerance, contradicting safety mandates for car seat positioning.

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