A nurse manager is updating protocols for the use of belt restraints.
Which of the following guidelines should the nurse manager include?
Request a PRN restraint prescription for clients who are aggressive.
Document the client's condition every 15 min.
Attach the restraint to the bed's side rails.
Remove the client's restraint every 4 hr.
The Correct Answer is B
Answer is: b. Document the client's condition every 15 min.
Explanation: The nurse manager should include the guideline to document the client's condition every 15 minutes while using belt restraints. This is to ensure close monitoring of the client's physical and psychological well-being and to evaluate the ongoing need for restraint use.
Choice a. is wrong because requesting a PRN restraint prescription for clients who are aggressive might not be appropriate. The use of restraints should be based on a thorough assessment of the client's condition and should be the least restrictive method possible.
Choice c. is wrong because attaching the restraint to the bed's side rails poses a safety risk to the client, as the side rails can be lowered accidentally or intentionally, leading to potential injury.
Choice d. is wrong because removing the client's restraint every 4 hours might not be appropriate, as it depends on the client's specific needs, facility policies, and state regulations. The nurse should follow appropriate guidelines for removing restraints and reassess the client's need for continued restraint use.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Research consistently shows that individuals who have a history of violent behavior are at a higher risk of engaging in future violent acts. This is a significant predictor because past behavior is often indicative of future behavior. Individuals with a history of violence may have difficulty managing anger, frustration, or stress, making them more prone to aggressive tendencies in various situations.
Choice B rationale:
Experiencing delusions refers to having false beliefs that are firmly held despite evidence to the contrary. While delusions can lead to erratic behavior, not all individuals experiencing delusions will become violent. The presence of delusions alone is not as strong a predictor of future violence as a documented history of violent behavior.
Choice C rationale:
While statistical data may indicate that males are more commonly involved in violent crimes, it is important to note that gender alone is not a reliable predictor of an individual's likelihood to become violent. Many males never engage in violent behavior, and focusing solely on gender overlooks crucial individual factors that contribute to violent tendencies.
Choice D rationale:
Having a history of being in prison suggests past involvement in criminal activities, but it does not directly predict future violent behavior. Some individuals may have been incarcerated for non-violent offenses or may have undergone rehabilitation, reducing their propensity for violence. Therefore, this choice is not as strong a predictor as previous violent behavior.
Correct Answer is B
Explanation
Choice A rationale:
Belching is a common finding following an esophagogastroduodenoscopy and is not a cause for concern unless it is excessive or accompanied by other concerning symptoms.
Choice B rationale:
(Correct Choice) Abdominal pain after an esophagogastroduodenoscopy can indicate complications such as perforation, bleeding, or infection. It is essential to report this finding to the provider promptly for further evaluation and management.
Choice C rationale:
Sore throat is a common and expected side effect after the procedure due to irritation from the endoscope. It usually resolves on its own and does not require immediate reporting unless it worsens or is associated with other concerning symptoms.
Choice D rationale:
Flatulence is not typically related to an esophagogastroduodenoscopy and is not a cause for concern in this context.
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