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 B

Explanation

The priority for the nurse is to assess the client's safety and risk of self-harm or suicide, which may increase during a situational crisis. The other questions are also important to explore, but they are not as urgent as assessing for suicidal ideation or intent.

A. Decreased heart rate B. Hyperthermia C. Hyperglycemia D. Decreased blood pressure

Correct Answer is B

Explanation

Alcohol withdrawal syndrome is characterized by autonomic hyperactivity, which can manifest as tachycardia, hypertension, hyperthermia, diaphoresis, tremors, seizures, and delirium tremens. The nurse should monitor the client's vital signs, provide supportive care, and administer medications as prescribed to prevent complications and promote recovery.

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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

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Correct Answer is B

Explanation

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