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 D
Explanation
A. Neuroleptic malignant syndrome is a rare, life-threatening reaction associated with antipsychotic medications, not stimulants like methylphenidate.
B. Dystonia, akinesia, and extrapyramidal symptoms are primarily seen with antipsychotic use, not with ADHD stimulant medications.
C. Bradycardia and hypotensive episodes – Stimulants more commonly cause tachycardia and hypertension, not bradycardia or hypotension.
D. Sleep disturbances and weight loss are common side effects of methylphenidate due to its stimulant properties. Monitoring sleep patterns, appetite, and growth is a priority in children taking this medication.
Correct Answer is B
Explanation
A. Methadone (Methadose) is used as opioid replacement therapy to prevent withdrawal symptoms, not primarily to maintain abstinence.
B. Naltrexone (Vivitrol) is an opioid antagonist that helps maintain abstinence in patients with alcohol or opioid dependence by reducing cravings and blocking the euphoric effects of these substances.
C. Disulfiram (Antabuse) is used specifically for alcohol dependence; it causes unpleasant reactions if alcohol is consumed but does not address opioid addiction.
D. Bromocriptine (Parlodel) is used for Parkinson’s disease and certain endocrine disorders; it is not indicated for maintaining abstinence from alcohol or opioids.
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