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 A

Explanation

Levothyroxine is a medication used to treat hypothyroidism, and monitoring the TSH levels helps determine the effectiveness of the medication.

Blood urea nitrogen (BUN) is a test used to assess kidney function and is not specifically related to thyroid function or levothyroxine therapy.

Prothrombin time (PT) is a test used to evaluate the clotting ability of the blood and is not directly related to thyroid function or levothyroxine therapy.

Arterial blood gases (ABGs) are used to assess oxygen and carbon dioxide levels in the blood and evaluate acid-base balance. ABGs are not specifically related to thyroid function or levothyroxine therapy.

A. Administer the medication to the toddler each evening. B. Provide an additional dose of the medication prior to physical activity. C. Mix the medication in juice prior to administration. D. Administer the medication when the toddler has an acute asthma attack.

Correct Answer is A

Explanation

Explanation

A. Administer the medication to the toddler each evening.

Montelukast is a long-term control medication used for the management of asthma in both children and adults. It is typically taken once daily in the evening to provide continuous asthma control. Consistency in taking the medication is important to maintain its effectiveness.

Providing an additional dose of the medication prior to physical activity in (option B) is not a standard recommendation for montelukast use. Montelukast is not a rescue medication and does not provide immediate relief for asthma symptoms triggered by physical activity. In such cases, a short-acting bronchodilator medication, such as albuterol, is commonly used prior to physical activity.

Mixing the medication in juice prior to administration in (option C) is not recommended unless specifically instructed by the healthcare provider or indicated in the medication instructions.

Montelukast is available in various formulations, including chewable tablets and granules, which can be taken directly or mixed with certain foods or liquids. However, the specific instructions should be followed as provided by the healthcare provider or medication label.

Administering the medication when the toddler in (option D) has an acute asthma attack is not the intended use of montelukast. Montelukast is a long-term control medication aimed at preventing asthma symptoms and maintaining asthma control over time. For acute asthma attacks, a short-acting bronchodilator medication is typically used.

Therefore, the nurse should instruct the parents to administer the medication to the toddler each evening (option A) as part of the routine, long-term management of asthma.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a prescription for levothyroxine. Which of the following laboratory tests should the nurse monitor?

Correct Answer is A

Explanation

A nurse is reinforcing teaching with the parents of a toddler who has a new diagnosis of asthma and a prescription for montelukast. Which of the following instructions should the nurse include in the teaching?

Correct Answer is A

Explanation

A nurse in a provider's office is caring for a group of clients who have communicable diseases. Which of the following infections should the nurse report to the state health department?

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