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 B

Explanation

In Islam, it is customary to position the deceased's head toward Mecca, which is considered the holiest city in Islam. Mecca is the direction toward which Muslims face during prayer. Orienting the client's head toward Mecca is a sign of respect for their religious beliefs and customs.

While it is common in some cultural and religious practices for family members to stay with the deceased until burial, this may vary depending on the specific beliefs and customs of the family. It is important to respect the family's wishes and cultural practices, but it is not solely specific to Islam.

The duration of time for a family member to stay with the deceased can vary depending on cultural and religious practices, but there is no specific set duration of 8 hours in Islamic customs.

In Islam, the direction of Mecca is significant, and positioning the client's head toward Mecca is the customary practice. There is no specific requirement to position the head northward in Islamic customs.

A. Fidelity involves keeping promises made to clients. B. Fidelity involves making sure clients are able to make their own health care decisions. C. Fidelity involves ensuring that we do no harm to the client. D. Fidelity involves treating every client with the same level of respect.

Correct Answer is A

Explanation

A. Fidelity involves keeping promises made to clients

Fidelity is an ethical principle that pertains to the nurse's duty to be faithful, loyal, and keep promises made to clients. It involves acting in a trustworthy and reliable manner, maintaining commitments, and upholding the client's rights and autonomy.

Option B is incorrect because it refers to autonomy, which is another ethical principle that involves respecting the client's right to make their own health care decisions.

Option C is incorrect because it refers to nonmaleficence, which is the principle of ensuring that we do no harm to the client and avoiding actions that may cause harm or have a negative impact on the client's well-being.

Option D is incorrect because it refers to justice, which involves treating every client with fairness, equality, and respect, but it does not specifically address the concept of fidelity.

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Naxlex Comprehensive Predictor Exams

A nurse is assisting with postmortem care for a client who was a devout follower of Islam. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is reviewing information about ethical client care with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of fidelity?

Correct Answer is A

Explanation

A nurse is reviewing the plan of care for a group of clients. The nurse should identify that informed consent is required for which of the following procedures?

A nurse is assisting with a community health presentation about home safety precautions when there is an outdoor chemical disaster nearby. Which of the following instructions should the nurse include?

A nurse is implementing a bladder training program for a client who had a stroke. Which of the following interventions should the nurse take first?

A nurse is contributing to the plan of care for a client who is experiencing delirium. Which of the following interventions should the nurse recommend?

A nurse is contributing to the plan of care for a client who has leukemia and is experiencing chronic fatigue. Which of the following interventions should the nurse plan to include?

A nurse enters a client's room and finds her sitting on the floor next to the shower. The client states that she slipped on some water outside of the shower. Which of the following actions should the nurse take first?

A charge nurse in a long-term care facility notices the smell of alcohol on a nurse's breath. Which of the following actions should the nurse take first?

A nurse is reinforcing teaching with a parent of a child who has asthma about the administration of montelukast. Which of the following statements by the parent indicates an understanding of the teaching?