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

Explanation:

Yogurt can be beneficial for individuals with irritable bowel syndrome (IBS) because it contains probiotics, which are live bacteria that can help promote a healthy balance of gut bacteria.

Probiotics have been shown to potentially alleviate symptoms of IBS, such as bloating, gas, and abdominal discomfort. Additionally, yogurt is a good source of calcium and protein.

B- On the other hand, "Honey" is not specifically recommended for individuals with IBS as it can be a source of fermentable carbohydrates and may contribute to symptoms such as bloating and gas in some individuals.

C- "Watermelon" is generally well-tolerated by most people and can be included in the diet of individuals with IBS, as it is low in FODMAPs (fermentable carbohydrates that can trigger IBS symptoms in some individuals).

D- "Ice cream" is not typically recommended for individuals with IBS, as it often contains high amounts of fat and lactose, which can aggravate symptoms in some individuals. However, this can vary depending on the individual's tolerance to dairy and fat.

A. Keep the airbag on if the car seat is in the front seat B. Put a small cushion under the newborn's head for support C. Place the shoulder harnesses at the level of the infant's shoulders. D. Position the car seat at a 90 angle.

Correct Answer is C

Explanation

The shoulder harnesses of the car seat should be adjusted to fit the infant properly. The straps should be positioned at or below the level of the infant's shoulders to ensure a secure fit and proper restraint.

Infants should always be placed in a rear-facing car seat in the back seat of the vehicle. If the car seat is placed in the front seat, the airbag should be turned off to prevent potential harm to the infant in case of airbag deployment.

Do not put a small cushion under the newborn's head for support: It is important to follow the manufacturer's guidelines for the specific car seat being used. Additional cushions or supports should not be added to the car seat as they can interfere with the proper fit and safety of the seat. The infant's head should be supported by the car seat itself.

Infants should be placed in a rear-facing car seat at a reclined angle of approximately 45 degrees. This helps to keep the infant's airway open and provides proper support for their head and neck.

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Naxlex Comprehensive Predictor Exams

A nurse is assisting a client who has irritable bowel syndrome with meal selections. Which of the following foods should the nurse remind the client to include in her diet?

Correct Answer is A

Explanation

A nurse is reinforcing teaching with new parents about car seat safety. Which of the following instructions should the nurse include?

Correct Answer is C

Explanation

A nurse is collecting data for a client who is receiving enteral tube feedings. The nurse should identify that which of the following findings is a manifestation of fluid overload?

A charge nurse is reinforcing teaching with a newly licensed nurse about infection control measures. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

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A nurse in an assisted-living facility is reinforcing teaching with staff members about preparing for an external chemical disaster. Which of the following instructions should the nurse include?