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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Stop the newly licensed nurse from administering the medication – While it is important to prevent the administration of medication against the client's will, the focus should initially be on de-escalation to address the client's refusal.
B. Demonstrate how to verbally de-escalate the situation – This is the most appropriate first action. De-escalation techniques can help calm the client and create a dialogue, potentially leading to a willingness to discuss the medication and its benefits.
C.discussing the medication's purpose, is also secondary to honoring the client's current refusal.
D.assessing the need for restraints, would be inappropriate without first stopping the medication administration and could escalate the situation. Therefore, the first and most critical action is to stop the medication administration.
Correct Answer is B
Explanation
The nurse should respect the client's privacy and confidentiality and obtain their consent before disclosing any information to their employer or anyone else who is not directly involved in their care. Contacting the legal department, the provider, or the client's family may be appropriate in some situations, but they are not necessary or ethical actions without the client's permission.
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