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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Massaging a DVT risks dislodging the clot, causing embolism. In postpartum with anticoagulants, this is contraindicated to prevent lethal complications.
Choice B reason: Bed rest minimizes clot movement in DVT, aiding anticoagulation postpartum. It reduces embolism risk, a critical safety measure in this scenario.
Choice C reason: Ice may reduce swelling, but it’s not standard for DVT with anticoagulants. Elevation and rest are prioritized over cold therapy here.
Choice D reason: Aspirin isn’t used with anticoagulants like heparin; it increases bleeding risk. Postpartum DVT needs specific pain management, not this drug.
Correct Answer is A
Explanation
Choice A reason: Steri-strips support incision healing post-laparoscopy, falling off naturally in 7-10 days. This shows correct understanding of wound care instructions.
Choice B reason: Prolonged nausea isn’t expected post-cholecystectomy; it’s minimal with laparoscopy. Persistent symptoms suggest complications, not normal recovery understanding.
Choice C reason: High-fat diets strain digestion post-gallbladder removal, causing discomfort. Low-fat is advised, so this reflects a recovery misconception.
Choice D reason: Diarrhea may occur briefly, but not until diet shifts. Expecting it long-term misinterprets bile adjustment, needing dietary clarification.
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