An adult patient assaulted another patient and was then restrained. One hour later, which statement by the restrained patient requires the nurse's immediate attention?
"I hate all of you!"
"The other patient started the fight."
"You wait until I tell my lawyer."
"My fingers are tingly."
The Correct Answer is D
A. "I hate all of you!" –This reflects the patient’s anger and hostility, which is expected after being restrained. While it requires therapeutic communication, it does not signal a medical emergency.
B. "The other patient started the fight." – This statement is defensive and attempts to shift blame. Although it provides insight into the patient’s thought process, it is not urgent from a physiological standpoint.
C. "You wait until I tell my lawyer." – This reflects frustration and a threat of legal action. It is important for documentation and de-escalation but does not require immediate clinical intervention.
D. "My fingers are tingly." – This is the highest priority because it indicates impaired circulation or nerve compression related to the restraints. Tingling, numbness, coolness, or pallor are warning signs that restraints are too tight or causing neurovascular compromise. This can lead to permanent injury if not corrected promptly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Aripiprazole is an atypical antipsychotic with a lower risk of weight gain, metabolic syndrome, and hypertension compared with olanzapine or clozapine, making it suitable for a patient who is overweight and hypertensive. It effectively treats positive symptoms such as auditory hallucinations and may improve social functioning.
B. Olanzapine is effective for schizophrenia but is associated with significant weight gain, hyperlipidemia, and worsening hypertension, making it less appropriate for this patient.
C. Clozapine is reserved for treatment-resistant schizophrenia due to risks of agranulocytosis, myocarditis, and metabolic side effects; it is not first-line for this patient.
D. Ziprasidone has a lower risk of metabolic side effects than olanzapine or clozapine, but it carries a risk of QT prolongation, which may be concerning in hypertensive patients with potential cardiac risks.
Correct Answer is ["B","C","F","I"]
Explanation
A. Blood pressure – Within normal range (115/76 mm Hg). No immediate concern.
B. Lithium level – 1.7 mEq/L is above the therapeutic range (0.8–1.2). Toxicity is likely, especially with the client’s symptoms (tremor, confusion, GI upset). Requires urgent follow-up.
C. Sodium level – 128 mEq/L indicates hyponatremia. Low sodium increases the risk for lithium toxicity because lithium and sodium compete for renal reabsorption.
D. WBC count – Within normal range (7,000/mm³).
E. TSH level – Mildly elevated (6). Suggests hypothyroidism (a side effect of lithium) but not immediately life-threatening. Requires follow-up, but not urgent.
F. BUN level –Elevated at 30 mg/dL (normal 10–20). Indicates impaired renal function, which reduces lithium clearance and increases toxicity risk.
G. Levothyroxine dosage – No immediate safety issue noted; managed long term.
H. Acetaminophen – Daily 325 mg is safe; not a concern.
I. Lithium dosage – Current dose (600 mg BID) is likely contributing to toxicity and must be reassessed immediately.
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