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 B

Explanation

Choice A reason: Hypocalcemia may occur in AKI due to impaired vitamin D activation, but it is not a primary concern in the diuresis phase, where kidneys produce large urine volumes. Calcium imbalances are less immediate than fluid losses, which can rapidly destabilize hemodynamics during this phase.

Choice B reason: In the diuresis phase of AKI, kidneys regain function, producing excessive urine, which can lead to hypovolemia. Fluid loss depletes intravascular volume, causing hypotension, tachycardia, and organ hypoperfusion. Monitoring is critical to prevent dehydration and ensure adequate fluid replacement to maintain hemodynamic stability during recovery.

Choice C reason: Increased blood pressure is more common in the oliguric phase of AKI due to fluid overload. In the diuresis phase, excessive urine output reduces volume, potentially lowering blood pressure. Hypertension is not a typical complication during this phase, making it an incorrect focus for monitoring.

Choice D reason: Hyperkalemia is a concern in the oliguric phase of AKI due to reduced potassium excretion. In the diuresis phase, increased urine output facilitates potassium clearance, reducing hyperkalemia risk. Hypovolemia from excessive fluid loss is a more immediate concern during this phase of AKI recovery.

A. Say to the interrupting patient, “I am not available to talk with you at the present time” B. End the unproductive session with the current patient and spend time with the patient who has just interrupted C. Invite the interrupting patient to join in the session with the current patient D. Tell the patient who interrupted, “This session will be 5 more minutes; then, I will talk with you”

Correct Answer is D

Explanation

Choice A reason: Bluntly stating unavailability dismisses the interrupting patient’s needs without offering a solution, potentially escalating distress. This approach lacks therapeutic communication, as it fails to acknowledge the patient’s urgency or provide a clear plan, which is critical in maintaining trust in a mental health setting.

Choice B reason: Ending the current session prematurely disrespects the silent patient’s therapeutic process. Silence may reflect processing or discomfort, requiring time to build trust. Abruptly shifting focus undermines the current patient’s care, potentially worsening their mental health and disrupting the therapeutic relationship.

Choice C reason: Inviting the interrupting patient to join violates confidentiality and disrupts the current patient’s safe space. Combining sessions without consent breaches ethical principles, potentially causing discomfort or mistrust, which hinders therapeutic progress for both patients in a mental health context.

Choice D reason: Acknowledging the interruption and scheduling a follow-up in 5 minutes respects both patients’ needs. It maintains the current patient’s therapeutic time while addressing the interrupting patient’s urgency, ensuring fairness and trust. This approach upholds ethical care and supports a therapeutic environment for mental health treatment.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is in the diuresis phase of acute kidney injury. The nurse should closely monitor the client for what complication during this phase?

Correct Answer is B

Explanation

A nurse is talking with a patient, and 5 minutes remain in the session. The patient has been silent for most of the session. Another patient comes to the door of the room, interrupts, and says, “I really need to talk to you right now.” The nurse should:

Correct Answer is D

Explanation

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