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 B
Explanation
A. Seclusion is a last-resort intervention, not an initial step.
B. Staff meetings to ensure consistent approaches, structure, and limit-setting prevent staff fatigue, reduce defensiveness, and provide therapeutic consistency for the client.
C. Confronting the patient directly about unacceptable behavior may escalate agitation and is not the most effective prevention strategy.
D. Group discussions with patients about one individual’s behavior would be inappropriate and non-therapeutic.
Correct Answer is A
Explanation
A. Magical thinking involves belief that one has special powers or that thoughts/actions can influence unrelated events. Claiming an ability to decode DNA by sight reflects an irrational belief in a special, unrealistic power.
B. Ideas of reference are the belief that neutral events (TV, conversations) refer specifically to oneself; that is not described here.
C. Visual hallucinations are false sensory perceptions (seeing things that aren't there); the statement describes a belief about an ability, not a sensory experience.
D. Thought insertion is the delusional belief that others are putting thoughts into one’s mind; the patient is claiming a personal ability, not externally implanted thoughts.
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