An adult client was put in restraints after all other attempts to reduce aggression have failed. Which is required now that restraints have been instituted by the nurse?

A documented nursing assessment every hour

Constant one-on-one supervision during the first hour and then video monitoring

A face-to-face evaluation by the psychiatrist within one hour of restraint

Review of the appropriateness of restraints every hour

Answer and Explanation

The Correct Answer is C

Choice A reason: Hourly nursing assessments are important for monitoring safety in restraints but are not the primary legal requirement. Assessments ensure no physical harm, but psychiatric evaluation within one hour is mandated to confirm restraint necessity, making this option secondary in priority for immediate post-restraint protocol.

Choice B reason: Constant supervision may be used, but transitioning to video monitoring after one hour does not meet strict regulatory standards for restraints. Face-to-face psychiatric evaluation within one hour is required to assess ongoing need and ensure patient rights, making this option less accurate for legal compliance.

Choice C reason: Regulatory standards (e.g., CMS, Joint Commission) mandate a face-to-face evaluation by a psychiatrist within one hour of initiating restraints to assess necessity, safety, and alternatives. This ensures compliance with mental health laws, protects patient rights, and prevents overuse, making it the required action.

Choice D reason: Reviewing restraint appropriateness hourly is part of ongoing care but is not the primary requirement. A psychiatrist’s face-to-face evaluation within one hour takes precedence to ensure legal and ethical use, as it confirms the clinical justification for restraints, making this option secondary.

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Correct Answer is D

Explanation

Choice A reason: The right to do no harm (nonmaleficence) is an ethical principle, not a specific client right. While premature restraints may cause harm, this option does not directly address the legal right violated, which is the use of least restrictive interventions, making it less precise.

Choice B reason: Informed consent involves agreeing to treatments, not the use of restraints, which is a safety intervention. While clients should be informed, premature restraint use violates the right to least restrictive care, not consent, as restraints are not typically consensual interventions.

Choice C reason: Confidential and respectful care relates to privacy and dignity, not the method of intervention. Premature restraints violate the principle of using less invasive options first, not confidentiality or respect, making this right irrelevant to the specific violation described in the scenario.

Choice D reason: The right to least restrictive treatment requires using non-invasive interventions (e.g., de-escalation) before restraints. Premature restraint use violates this right, as mental health laws mandate the least coercive measures to ensure safety, prioritizing patient autonomy and minimizing harm, making this the correct answer.

A. Advance the catheter 2 to 4 cm further into the peritoneal cavity B. Infuse 50 mL of additional dialysate C. Aspirate from the catheter using a 60-mL syringe D. Reposition the client to facilitate drainage

Correct Answer is D

Explanation

Choice A reason: Advancing the catheter further risks perforation or malposition, potentially damaging peritoneal tissues or organs. Slow drainage is often due to positional obstruction or constipation, not catheter depth. This invasive action requires medical orders and imaging confirmation, making it inappropriate as a first step in addressing slow drainage.

Choice B reason: Infusing additional dialysate worsens abdominal distension and does not address slow drainage. It may increase intra-abdominal pressure, causing discomfort or complications like hernia. The issue is outflow obstruction, not insufficient dialysate, so adding more fluid is counterproductive and could exacerbate the client’s condition.

Choice C reason: Aspirating with a syringe is not standard practice and risks introducing infection or damaging the catheter. It does not address underlying causes like positional obstruction or fibrin clots. Medical evaluation or specialized interventions like heparin instillation are needed for persistent drainage issues, making this action inappropriate.

Choice D reason: Repositioning the client facilitates drainage by relieving positional obstructions, such as catheter kinking or omental wrapping, common in peritoneal dialysis. Changing positions (e.g., side-lying or sitting) promotes gravity-assisted flow, reducing abdominal girth and improving exchange efficiency. This non-invasive action is the safest and most effective initial step.

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An adult client was put in restraints after all other attempts to reduce aggression have failed. Which is required now that restraints have been instituted by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The client feels that the client’s rights have been violated. Placing a client in restraints before using other methods of intervention violates which of the client’s rights?

Correct Answer is D

Explanation

A client diagnosed with chronic kidney disease is completing an exchange during peritoneal dialysis. The nurse observes that the peritoneal fluid is draining slowly and that the client’s abdomen is increasing in girth. What is the nurse’s most appropriate action?

Correct Answer is D

Explanation

The nurse is sitting down with a client to begin a conversation. Which position will the nurse take to convey acceptance of the client?

Which of the following would the nurse expect to find when reviewing the laboratory test results of a client with renal failure?

Which statement about nonverbal communication is accurate?

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The nurse is performing an admission assessment for a client on the behavioral health unit with depression and anxiety. Which goal of therapeutic communication will the nurse prioritize?

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