A nurse on a mental health unit placed a client in mechanical restraints after the client assaulted another client. Which of the following actions should the nurse take?

Evaluate the client hourly while the restraints are applied.

Have the provider assess the client within 1 hr after applying the restraints.

Obtain a prescription for restraints on an as-needed basis.

Request that the provider renew the prescription for restraints every 8 hr.

Answer and Explanation

The Correct Answer is B

The nurse should have the provider assess the client within 1 hr after applying restraints to ensure that the restraints are necessary and appropriate, and to monitor the client's physical and mental status.

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Correct Answer is ["A","B","D","E"]

Explanation

Hypotension, bradycardia, lanugo, and Russell's sign. Rationale: Hypotension and bradycardia are common manifestations of anorexia nervosa due to dehydration, electrolyte imbalance, and decreased cardiac output. Lanugo is fine hair that covers the body as a result of decreased body fat and thermoregulation. Russell's sign is calluses or scars on the knuckles or hands from self-induced vomiting. Diarrhea is not a typical finding of anorexia nervosa.

A. Tell the client he cannot refuse the treatment because he was involuntarily committed. B. Inform the client that ECT does not require client consent. C. Document the client's refusal of the treatment in the medical record. D. Ask the client's family to encourage the client to receive ECT.

Correct Answer is C

Explanation

The nurse should respect and document the client's right to refuse treatment, even if he was involuntarily committed, unless there is a court order for ECT. The nurse should not coerce, misinform, or pressure the client to receive ECT against his will. 22.

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A nurse on a mental health unit placed a client in mechanical restraints after the client assaulted another client. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has anorexia nervosa. Which of the following findings should the nurse expect? (Select all that apply.)

Correct Answer is ["A","B","D","E"]

Explanation

A nurse is caring for a client who was involuntarily committed and is scheduled to receive electroconvulsive therapy (ECT). The client refuses the treatment and will not discuss why with the health care team. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is caring for a client who has anorexia nervosa. Which of the following findings requires immediate intervention by the nurse?

An older adult client is brought to the mental health clinic by her daughter. The daughter reports that her mother is not eating and seems uninterested in routine activities. The daughter states, "I'm so worried that my mother is depressed." Which of the following responses should the nurse make?

A nurse is caring for a client who has borderline personality disorder and has been engaging in self-mutilation. The nurse should encourage the client to participate in which of the following groups?

A nurse is assessing a client who recently experienced the loss of their partner. Which of the following questions is the priority for the nurse to ask during this situational crisis?

A nurse is leading a critical incident stress debriefing with a group of staff members following a mass trauma incident. Which of the following interventions should the nurse take first?

A nurse in an in-patient facility is caring for a client who has an anxiety disorder. Which of the following actions should the nurse take while the client is experiencing an acute panic attack?

A nurse is providing behavioral therapy for a client who has obsessive-compulsive disorder. The client repeatedly checks that the doors are locked at night. Which of the following instructions should the nurse give the client when using thought stopping technique?