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."

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Making positive statements about body image is important for psychological recovery but is secondary to restoring physical health.

B. Achieving a healthy weight is the priority goal, as physical stabilization is essential to prevent life-threatening complications of malnutrition.

C. Feeling in control of behavior is a therapeutic goal, but it is not the immediate priority compared to addressing life-threatening weight loss.

D. Identifying family dynamics is important for long-term support and autonomy but is secondary to immediate physical health needs.

A. Delayed language development B. Consistent limit testing C. Short attention span D. Spinning a toy repetitively E. Ritualistic behavior

Correct Answer is ["A","D","E"]

Explanation

A. Children with autism spectrum disorder (ASD) often demonstrate delayed or impaired language development.
B. Consistent limit testing is more characteristic of oppositional defiant disorder (ODD), not ASD.
C. A short attention span is more typical of ADHD, not ASD.
D. Repetitive motor behaviors (e.g., spinning toys, flapping hands) are hallmark features of ASD.
E. Ritualistic or rigid routines/behaviors are common in ASD, and disruptions may cause significant distress.

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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?

Nursing Test Bank

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