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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale:

This statement indicates a delusion, not a command hallucination. Delusions are fixed false beliefs that are not based in reality.

Choice B rationale:

This statement indicates a command hallucination. Command hallucinations involve hearing voices that direct the person to take action.

Choice C rationale:

This statement indicates paranoia, not a command hallucination. Paranoia involves intense anxious or fearful feelings and thoughts often related to persecution or threat.

Choice D rationale:

This statement indicates a visual hallucination, not a command hallucination. Visual hallucinations involve seeing things that aren’t there.

A. Excessively anxious. B. Withdrawn behaviors. C. Exploitive of others. D. Blunted affect.

Correct Answer is C

Explanation

Choice A rationale:

Excessive anxiety is not typically associated with antisocial personality disorder. It is more commonly seen in anxiety disorders.

Choice B rationale:

Withdrawn behaviors are more commonly associated with disorders such as depression or social anxiety disorder, not antisocial personality disorder.

Choice C rationale:

Exploiting others is a common characteristic of antisocial personality disorder. Individuals with this disorder often manipulate or deceive others for personal gain.

Choice D rationale:

Blunted affect, or reduced emotional expression, is not typically associated with antisocial personality disorder. It is more commonly seen in disorders such as schizophrenia.

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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?.

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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?.