A nurse on a mental health unit is caring for a client who is in restraints. Which of the following actions should the nurse take?

Release the client's restraints every 4 hr.

Check the client's status every hour.

Document the client's behavior leading to the initiation of the restraints.

Obtain written consent by the client for the placement of the restraints.

Release the client's restraints every 4 hr.

Check the client's status every hour.

Document the client's behavior leading to the initiation of the restraints.

Obtain written consent by the client for the placement of the restraints.

Answer and Explanation

The Correct Answer is C

Document the client's behavior leading to the initiation of the restraints: Accurate and comprehensive documentation is essential in the client's medical record. This includes documenting the client's behavior or actions that necessitated the use of restraints. It is important to document the reason, duration, and type of restraint used.

Release the client's restraints every 2 hours or as per institutional policy: It is important to periodically release the restraints to assess the client's circulation, skin integrity, and overall well-being. Restraints should never be kept on continuously without intermittent release. Check the client's status every 15 minutes: The nurse should closely monitor the client's vital signs, level of comfort, and any signs of distress or complications. Frequent assessment ensures early identification and intervention if any issues arise.

Obtain informed consent: While obtaining consent is necessary for many procedures or treatments, including the use of restraints, it is not applicable in situations where there is an imminent risk of harm to the client or others. The use of restraints in mental health units is based on legal and ethical guidelines, prioritizing the client's safety and the safety of others.

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Correct Answer is D

Explanation

The APN, also known as a nurse practitioner or clinical nurse specialist, has advanced knowledge and expertise in pharmacology and medication management. They are trained to assess medication interactions, evaluate potential risks, and provide guidance to ensure safe and effective medication use.

The other members of the interdisciplinary team listed are not specifically trained to address medication interactions:

Social workers focus on addressing psychosocial aspects of care, such as emotional support, counseling, and resource coordination. While they may provide valuable assistance in various areas of the client's care, they typically do not have specialized knowledge in medication interactions.

Patient care technicians, also known as nursing assistants or certified nursing assistants, provide direct patient care under the supervision of nurses. They do not typically have the training or authority to address medication interactions.

Psychologists specialize in the assessment, diagnosis, and treatment of mental and emotional health concerns. While they may be involved in the client's overall care, including medication management for mental health conditions, their expertise lies primarily in psychological assessment and therapy rather than medication interactions.

A. "I can have two glasses of wine with dinner." B. "I will set my blood pressure goal at 130 over 84. C. "I should decrease my salt intake to 2 grams per day." D. "I should exercise for 15 minutes two times per week."

Correct Answer is C

Explanation

"I should decrease my salt intake to 2 grams per day." - This statement is correct. Decreasing salt intake is an important dietary modification for individuals with hypertension. The general recommendation is to limit sodium intake to 2 grams per day or less. Reducing salt intake can help lower blood pressure levels.

"I can have two glasses of wine with dinner." - This statement is not accurate. While moderate alcohol consumption may have some health benefits, it is generally recommended to limit alcohol intake, especially for individuals with hypertension. The specific recommendation for alcohol consumption may vary depending on individual factors and should be discussed with a healthcare provider.

"I should exercise for 15 minutes two times per week." - This statement is not accurate. While any amount of physical activity is beneficial, the current recommendations for adults include at least 150 minutes of moderate-intensity aerobic activity or 75 minutes of vigorous-intensity aerobic activity per week, along with muscle-strengthening activities on two or more days. The client should aim for a higher frequency and duration of exercise to achieve optimal health benefits.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is taking multiple medications and asks about possible interactions. To which of the following members of the interdisciplinary team should the nurse make a referral?

Correct Answer is D

Explanation

A nurse is reinforcing teaching about healthy lifestyle changes with a female client who has mild hypertension. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is C

Explanation

A nurse is collecting data from a client who reports feeling stress. Which of the following should the nurse identify as an external stressor?

A nurse is completing documentation in the medical record about a client who fell on the floor. Which of the following statements should the nurse include in the documentation?

A nurse is reinforcing teaching about circumcision care with the parent of an infant who just underwent a Plastibell circumcision. Which of the following statements by the parent indicates an understanding of the teaching?

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A nurse is assisting with the admission of a client who has varicella zoster. Which of the following interventions should the nurse plan to implement?

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