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?

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

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

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

Evaluate the client hourly while the restraints are applied.

Answer and Explanation

The Correct Answer is B

A. Obtain a prescription for restraints on an as-needed basis:
Restraints should never be used on an as-needed basis without a specific, individualized order from a healthcare provider. Restraints are a significant intervention that should only be used when necessary, and they require a clear prescription outlining the duration, reason, and method of application.

B. Have the provider assess the client within 1 hour after applying the restraints:
This option is the correct choice. It is crucial to involve the healthcare provider promptly after restraints are applied. The provider needs to assess the patient's physical and mental status, and the appropriateness of the restraints, and consider alternatives or modifications to the intervention. Regular assessments ensure the patient's safety and well-being while addressing the initial reason for applying restraints.

C. Request that the provider renew the prescription for restraints every 8 hours:
Restraining a patient every 8 hours without ongoing assessment and a clear clinical rationale is inappropriate and goes against best practices. Restraints should only be used when absolutely necessary and should be reevaluated frequently. Requesting a renewal on a fixed schedule without considering the patient's changing condition is not a safe or ethical approach.

D. Evaluate the client hourly while the restraints are applied:
While regular monitoring of a patient in restraints is essential, evaluating the patient every hour might not be sufficient, especially in the early stages after the application of restraints. The patient should be continuously monitored, with assessments conducted more frequently, especially immediately after applying the restraints, to ensure their safety and well-being.

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Correct Answer is A

Explanation

A. Pseudoephedrine
Clients taking phenelzine, which is a monoamine oxidase inhibitor (MAOI) used to treat depression, need to avoid certain over-the-counter medications, especially those containing sympathomimetic amines like pseudoephedrine. Combining MAOIs with sympathomimetic medications can lead to a severe increase in blood pressure, potentially causing a hypertensive crisis.

B. Docusate sodium:
Docusate sodium is a stool softener and is generally safe to use with phenelzine. It does not have significant interactions with MAOIs.

C. Ranitidine:
Ranitidine is an H2 blocker used to reduce stomach acid production. It does not have significant interactions with phenelzine.

D. Ibuprofen:
Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) used for pain and inflammation. While it does not interact directly with phenelzine, individuals taking phenelzine should avoid other medications, especially NSAIDs, that can increase the risk of bleeding due to phenelzine's effects on platelet function. However, this interaction is not as severe as the interaction between phenelzine and sympathomimetic medications like pseudoephedrine.

A. Long-term isolation B. Dysthymic disorder C. Alcohol intoxication D. Schizoid personality disorder

Correct Answer is C

Explanation

A. Long-term isolation: Long-term isolation, or social isolation, can lead to feelings of loneliness and depression. While prolonged isolation can contribute to mental health issues, it is not a direct risk factor for violent behavior. People who are socially isolated might suffer from emotional distress, but it doesn't necessarily make them violent.

B. Dysthymic disorder: Dysthymic disorder, also known as persistent depressive disorder, is a type of chronic depression. While individuals with dysthymic disorder may experience low moods and a lack of interest in activities, it doesn't inherently make them prone to violence. Depression is more likely to cause self-directed harm (such as self-harm or suicide) rather than violent behavior towards others.

C. Alcohol intoxication: Alcohol is a substance that impairs judgment and reduces inhibitions. When a person is intoxicated, they may act aggressively or violently, even in situations where they wouldn't normally do so. Alcohol intoxication can lead to a loss of control, impaired decision-making, and aggressive behavior, making it a significant risk factor for violent actions.

D. Schizoid personality disorder: Schizoid personality disorder is characterized by a lack of interest in social relationships, emotional coldness, and detachment. While individuals with this disorder may prefer to be alone and avoid social interactions, they are not necessarily prone to violent behavior. Schizoid personality disorder primarily affects social functioning rather than predisposing someone to violence.

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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 A

Explanation

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Correct Answer is C

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