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 C
Explanation
Choice A rationale:
Discussing a client’s information with staff who have provided care in the past is not appropriate unless it is necessary for the client’s current care.
Choice B rationale:
The provider does not need to give consent to discuss health information with the client’s family. The client is the one who must give consent.
Choice C rationale:
This statement is correct. A client retains the legal right to privacy of health information even after they have died.
Choice D rationale:
A provider may not speak to a client’s employer regarding a substance use disorder without the client’s consent.
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