When placing an agitated client in restraints, the nurse understands that which of the following must occur?

Documentation of the event will include interventions attempted prior to initiating restraints.

The physician must be present at the time of the restraint episode.

The client will be turned every 2 hours.

The client will need to be monitored every one-half hour.

Answer and Explanation

Correct Answer : A,C,D

Choice A Reason:

The statement “Documentation of the event will include interventions attempted prior to initiating restraints” is correct. Proper documentation is crucial when restraints are used. This includes detailing the client’s behavior that necessitated the restraint, the interventions attempted before applying the restraint, the type of restraint used, and the time it was applied. This documentation ensures transparency and accountability, and it helps in evaluating the necessity and appropriateness of the restraint use.

Choice B Reason:

The statement “The physician must be present at the time of the restraint episode” is incorrect. While a physician’s order is required for the use of restraints, the physician does not need to be physically present at the time of the restraint episode. However, the physician must evaluate the client within a specified time frame after the restraint is applied, typically within one hour. This ensures that the restraint is medically justified and that the client’s condition is appropriately monitored.

Choice C Reason:

The statement “The client will be turned every 2 hours” is correct. Clients in restraints must be regularly repositioned to prevent complications such as pressure ulcers and to ensure their comfort. Turning the client every 2 hours is a standard practice to maintain skin integrity and promote circulation. This intervention is part of the comprehensive care plan for clients in restraints.

Choice D Reason:

The statement “The client will need to be monitored every one-half hour” is correct. Frequent monitoring of clients in restraints is essential to ensure their safety and well-being. This includes checking for signs of distress, ensuring that the restraints are not causing harm, and assessing the client’s vital signs5. Monitoring every 30 minutes helps in promptly addressing any issues that may arise and ensures that the restraints are used safely and effectively.

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Correct Answer is ["0.63"]

Explanation

To calculate the correct dose:

Identify the prescribed dose: 5 mg
Identify the concentration of the available morphine: 8 mg/mL
Calculate the volume to be administered:
- Volume (mL) = Prescribed dose (mg) ÷ Concentration (mg/mL)
- Volume (mL) = 5 mg ÷ 8 mg/mL
- Volume (mL) = 0.625 mL

The nurse will give 0.63 mL (rounded to the nearest hundredth) for the correct dose.

A. “This is a difficult transition. Let’s formulate a plan to keep you feeling safe.” B. “It’s the policy that patients can only live here for 30 days. Let’s try to extend it.” C. “You’ve had a month to come up with a plan to work on your well-being.” D. “Hopefully you learned from being in counseling. I’m sure this will work out fine.”

Correct Answer is A

Explanation

Choice A Reason:

“This is a difficult transition. Let’s formulate a plan to keep you feeling safe.”

This response is the most supportive because it acknowledges the client’s feelings and offers a proactive solution. By recognizing the difficulty of the transition and suggesting a plan to ensure the client’s safety, the nurse provides reassurance and practical support. This approach helps to build trust and shows empathy, which is crucial in a therapeutic relationship.

Choice B Reason:

“It’s the policy that patients can only live here for 30 days. Let’s try to extend it.”

While this response acknowledges the client’s fear, it focuses on policy rather than addressing the client’s immediate emotional needs. Extending the stay might not be feasible or beneficial in the long term. The primary goal should be to empower the client to feel safe and supported outside the facility.

Choice C Reason:

“You’ve had a month to come up with a plan to work on your well-being.”

This response can come across as dismissive and unsupportive. It implies that the client should have already resolved their fears, which may increase their anxiety and feelings of inadequacy. The focus should be on providing immediate support and reassurance rather than criticizing the client’s progress.

Choice D Reason:

“Hopefully you learned from being in counseling. I’m sure this will work out fine.”

This response is overly optimistic and does not address the client’s current fears. It provides false reassurance without offering any concrete support or solutions. The client needs to feel heard and supported, not just reassured that everything will be fine.

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When placing an agitated client in restraints, the nurse understands that which of the following must occur?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["0.63"]

Explanation

As the discharge date for a client to leave gets closer, the client states, “I’m afraid to leave here. I’m afraid for my well-being and safety.” Which nursing statement is most supportive?

Correct Answer is A

Explanation

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