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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Explanation
A, Nervousness
Levothyroxine is a medication used to treat hypothyroidism, a condition in which the thyroid gland does not produce enough thyroid hormones. Thyrotoxicosis, on the other hand, is a condition characterized by an excess of thyroid hormones in the body, which can occur as a side effect of levothyroxine or other thyroid medications.
Nervousness is a common symptom of thyrotoxicosis. Excess thyroid hormones can lead to increased sympathetic nervous system activity, causing symptoms like nervousness, restlessness, anxiety, and palpitations.
Pruritus (itching) in (option B) is not correct because it is not a typical manifestation of thyrotoxicosis. Itching is not directly related to thyroid hormone levels and is more likely to be associated with other conditions or medication side effects.
Cough In (option C) is not correct because it is not a typical manifestation of thyrotoxicosis. Coughing is not a symptom directly related to thyroid hormone levels and is more likely to be associated with respiratory or other conditions.
Polyuria (increased urination) in (option D) is not correct because it is not a typical manifestation of thyrotoxicosis. Polyuria is not a symptom directly related to thyroid hormone levels and is more likely to be associated with other conditions, such as diabetes or kidney problems.
If the client experiences symptoms of thyrotoxicosis, such as nervousness, palpitations, or any other concerning signs, it is essential to notify the healthcare provider promptly. The provider may need to adjust the dosage of levothyroxine or consider other treatment options to address the excess thyroid hormone levels and ensure the client's well-been
Correct Answer is C
Explanation
Delirium is a state of acute confusion and cognitive impairment that can cause disorientation and difficulty with time perception. Reminding the client of the day and time frequently helps provide orientation and reduce confusion. It can help ground the client in reality and improve their understanding of their current circumstances.
Avoiding discussing the client's fears can hinder their ability to express and address their concerns. It is important to provide a safe and supportive environment where the client can communicate their fears and feelings.
Offering the client several choices at mealtimes might be overwhelming and confusing for someone experiencing delirium. It is generally better to provide structure and simplicity in their meal options, reducing decision-making demands.
Alternating daily caregivers can disrupt continuity of care and increase the client's confusion. Consistency in the caregiving team can help establish a therapeutic relationship and familiarity, which can aid in managing delirium.
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