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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

A. Liraglutide 0.6 mg subcutaneously daily:
Liraglutide is a medication used to treat type 2 diabetes and obesity. It works by regulating blood sugar levels and reducing appetite. It has no direct relevance to the treatment of schizophrenia or psychosis. Schizophrenia is a mental health disorder, and antipsychotic medications are typically used to manage its symptoms.

B. Selegiline 6 mg transdermal patch daily:
Selegiline is primarily used to treat Parkinson's disease by enhancing the effects of dopamine in the brain. It is not indicated for schizophrenia or psychosis. While dopamine dysregulation is involved in both Parkinson's disease and schizophrenia, the mechanisms and treatments are different. Antipsychotic medications, not selegiline, are used to manage psychosis in schizophrenia.

C. Aripiprazole 400 mg IM every 4 weeks:
This is the correct choice. Aripiprazole is an atypical antipsychotic medication commonly used to treat schizophrenia and other psychotic disorders. The intramuscular (IM) formulation provides extended release, making it suitable for clients who may have difficulty adhering to daily oral medications. It helps manage psychosis, a common symptom of schizophrenia.

D. Lithium 600 mg PO three times per day:
Lithium is a mood stabilizer commonly used to treat bipolar disorder by preventing or reducing the intensity of manic episodes. It is not a first-line treatment for schizophrenia or psychosis. Antipsychotic medications are the primary choice for managing the symptoms of psychosis in schizophrenia. Lithium is not typically used to address the hallucinations and delusions associated with schizophrenia.

A. "What have you done to change your situation?" B. "You should remove yourself from this situation now." C. “Are you thinking about harming yourself?" D. “We will help get you through this. You'll be fine."

Correct Answer is C

Explanation

A. "What have you done to change your situation?"
This response can come off as accusatory and might make the client feel judged. It's not the most therapeutic response in this situation.

B. "You should remove yourself from this situation now."
While removing oneself from a harmful situation is generally good advice, it might not be practical or safe in the heat of the moment. Moreover, this response doesn't address the underlying emotional distress the client is expressing.

C. “Are you thinking about harming yourself?"
This response directly assesses the client's suicidal ideation. It's essential to ask direct questions about self-harm when a person expresses feelings of hopelessness, as it provides an opportunity for the client to talk about their thoughts and feelings and for the nurse to assess the level of risk accurately.

D. “We will help get you through this. You'll be fine."
While offering support and reassurance is essential, it doesn't directly address the immediate concern of potential suicidal thoughts. The nurse should assess the client's safety first before providing reassurance.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 preparing to administer medications to a newly admitted client who has schizophrenia and is experiencing psychosis. Which of the following medications should the nurse plan to administer?

Correct Answer is C

Explanation

A nurse in an emergency department is caring for a client following a domestic dispute. The client states, "Nothing seems to go right for me and probably never will." Which of the following statements should the nurse make?

Correct Answer is C

Explanation

A nurse is providing teaching to a client who has a new prescription for tranylcypromine. Which of the following over-the-counter medications should the nurse instruct the client to avoid taking due to adverse interactions?

A nurse is planning to lead a support group for clients who have alcohol use disorder. One of the group members is a client who speaks a different language than the nurse. The nurse should ask which of the following individuals to assist with communication?

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 is obtaining a medical history from a client who is requesting a prescription for bupropion for smoking cessation. Which of the following assessment findings in the client's history should the nurse report to the provider?

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 is assessing a client who has paranoid personality disorder. Which of the following findings should the nurse expect?

A nurse is caring for a client who has major depressive disorder. After discussing the treatment with his partner, the client verbally agrees to electroconvulsive therapy (ECT) but will not sign the consent form. Which of the following actions should the nurse take?

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?