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 C

Explanation

Fontanels are soft spots on an infant's skull where the bones have not yet fused together. The anterior fontanel, located at the front of the head, typically closes between 12 to 18 months of age. The posterior fontanel, located at the back of the head, usually closes by 2 to 3 months of age.

The other findings mentioned are typical developmental milestones for a 4-month-old infant:

Rolling from back to abdomen: By 4 months of age, it is expected that infants can roll from their back to their abdomen. This is a normal developmental milestone.
Moves objects to mouth: At 4 months, infants begin to develop hand-eye coordination and the ability to reach for objects. Bringing objects to the mouth is a typical behavior at this age as infants explore their environment.

A. Use an N95 respirator. B. Instruct the parents to avoid bringing fresh flowers into the room. C. Initiate contact precautions. D. Place the child in a room that has a HEPA filtration system.

Correct Answer is C

Explanation

C. Initiate contact precautions

Clostridium difficile is a bacterium that causes diarrhea and can be easily transmitted from person to person. Contact precautions are necessary to prevent the spread of the infection. This includes wearing gloves and a gown when providing direct care to the child, ensuring proper hand hygiene, and implementing proper disinfection protocols for the environment.

The other options are not necessary or specific to the care of a child with Clostridium difficile:

Using an N95 respirator in (option A) is not necessary for the care of a child with Clostridium difficile. Respirators are typically used for airborne precautions, which are not indicated for this specific infection.

Instructing the parents to avoid bringing fresh flowers into the room in (option)is not specific to the care of a child with Clostridium difficile. While it is generally recommended to minimize potential sources of contamination in healthcare settings, this particular instruction is not specific to this infection.

Placing the child in a room with a HEPA filtration system in (option D) is not necessary for the care of a child with Clostridium difficile. HEPA filtration systems are typically used for airborne precautions, which are not indicated for this specific infection.

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Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a 4-month-old infant at a well-child visit. For which of the following findings should the nurse notify the provider?

Correct Answer is C

Explanation

A nurse is caring for a 2-year-old child who has Clostridium difficile. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is assisting with the care of a preschooler who has manifestations of respiratory syncytial virus. Which of the following actions should the nurse take?

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