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. Assessing lung sounds and extremities is not a priority in this context unless there are signs of fluid overload or other complications; it does not address the psychosocial aspect of anorexia recovery.
B. Positive reinforcement encourages the patient’s healthy behaviors and progress, helping to build motivation and self-esteem during the challenging refeeding process. Recognizing the patient’s achievement supports therapeutic engagement and adherence to treatment goals.
C. Immediately establishing a higher weight gain goal may increase anxiety or pressure on the patient, potentially undermining adherence and progress. Goals should remain realistic and individualized.
D. Suggesting aerobic exercise is inappropriate at this stage of refeeding, as excessive activity can interfere with weight restoration and may reinforce disordered behaviors.
Correct Answer is B
Explanation
A. Delirium is usually acute and reversible, especially when caused by an underlying condition like a UTI.
B. Delirium in elderly patients is often secondary to an acute illness such as a urinary tract infection. Treatment of the underlying cause typically resolves the confusion, so this statement provides accurate and reassuring information to the family.
C. While the provider can give a formal prognosis, the nurse can provide evidence-based, general information about delirium recovery.
D. While supportive, this does not address the family’s question about recovery.
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