A nurse is caring for a client who was placed in four-point restraints by the nursing staff following an episode of violent behavior.
Which of the following actions should the nurse take?.
Document the client's behavior in the medical record every 1 hr
Provide range-of-motion exercises to all extremities every 2 hr.
Request the provider renew the prescription in 24 hr.
Keep staff interactions with the client to a minimum.
The Correct Answer is B
Choice A rationale:
Documenting the client’s behavior every hour is not necessary. The nurse should monitor and document the client’s condition, but this does not need to be done every hour.
Choice B rationale:
Providing range-of-motion exercises to all extremities every 2 hours is important when a client is in restraints. This helps to prevent muscle stiffness and maintain circulation.
Choice C rationale:
The provider does not need to renew the prescription every 24 hours. The use of restraints should be reassessed regularly, but a new prescription is not required unless the restraints are removed and then need to be reapplied.
Choice D rationale:
Keeping staff interactions with the client to a minimum is not recommended. The client should be monitored closely and regular interaction can help to calm the client and reduce the need for restraints.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Discussing childhood memories during group therapy is a key component of reminiscence therapy. It helps older adults recall past experiences and can improve their mood and cognitive function.
Choice B rationale:
Playing board games can enhance cognition, but it’s not specific to reminiscence therapy.
Choice C rationale:
Making a unit calendar promotes orientation, but it’s not part of reminiscence therapy.
Choice D rationale:
Encouraging thought-stopping can help block undesirable thoughts, but it’s not a strategy used in reminiscence therapy.
Correct Answer is D
Explanation
Choice A rationale:
Absence of seizures is not an expected outcome of fluoxetine therapy. Fluoxetine is an antidepressant, not an anticonvulsant.
Choice B rationale:
Reduction in hand tremors is not an expected outcome of fluoxetine therapy. Fluoxetine is used to treat depression, obsessive-compulsive disorder, some eating disorders, and panic attacks.
Choice C rationale:
Decreased hallucinations is not an expected outcome of fluoxetine therapy. Fluoxetine is not typically used to treat conditions that cause hallucinations.
Choice D rationale:
Improved mood is an expected outcome of fluoxetine therapy. As an antidepressant, fluoxetine works by balancing chemicals in the brain that affect mood and emotions.
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