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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Stating intent to harm self and others meets criteria for involuntary hospitalization (e.g., 302 commitment), as it indicates imminent danger. Mental health laws prioritize safety, requiring inpatient evaluation to prevent suicide or violence, making this client eligible for involuntary admission to stabilize their condition.
Choice B reason: Refusing a diabetic diet is nonadherence but does not meet criteria for involuntary mental health hospitalization, which requires mental health-related danger to self or others. This behavior may warrant medical intervention, but it lacks the psychiatric urgency needed for involuntary admission.
Choice C reason: Uncontrolled rage with assaultive behavior indicates imminent danger to others, meeting criteria for involuntary hospitalization. Mental health laws allow commitment to protect others and stabilize the client, as assault reflects a severe mental health crisis requiring inpatient intervention to prevent further harm.
Choice D reason: Poor hygiene does not constitute imminent danger to self or others, a requirement for involuntary hospitalization. While it may indicate mental health issues, it lacks the acute risk needed for commitment, making outpatient evaluation or support more appropriate than involuntary admission.
Correct Answer is ["3.2"]
Explanation
The correct answer is 3.2 mL
Explanation:
Step 1 is identify the total dose ordered
800 mg
Step 2 is identify the concentration after reconstitution
Each mL contains 250 mg
Step 3 is divide the total dose by the concentration per mL
(800 ÷ 250) = 3.2
Result = 3.2 mL
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