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. While anesthesia is used, the side effects from it are not the main concern with ECT.
B. The most common side effects are mild confusion, headache, and short-term memory loss, which are typically temporary.
C. Muscle relaxants are given before the procedure to prevent cramping or injury from the seizure.
D. Myocardial infarction is not a common side effect; this response could unnecessarily alarm the spouse.
Correct Answer is D
Explanation
A. Stereotyped behavior, echopraxia, echolalia, and waxy flexibility are characteristic of the catatonic stage of schizophrenia, not the prodromal stage.
B. Auditory hallucinations, ideas of reference, thought insertion, and broadcasting are positive symptoms that typically emerge during the active stage of schizophrenia.
C. Loose associations, concrete thinking, and neologisms also represent active-phase symptoms and are not typical in the prodromal stage.
D. The prodromal stage is marked by subtle changes in behavior and cognition, including social withdrawal, misinterpretation of events, poor concentration, and preoccupation with unusual thoughts or religion. These signs precede the onset of full-blown psychotic symptoms.
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