PN Comprehensive Predictor 2023 Proctored Exam
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PN Comprehensive Predictor 2023 Proctored Exam
A nurse in an acute mental-health facility is caring for an adolescent who is exhibiting destructive behavior. Which of the following actions should the nurse take after applying physical restraints to the client?
Explanation
Choice A Reason: Planning to remove the restraints as soon as the client is calm is a correct action. Restraints should be used for the shortest duration necessary to ensure safety. Once the client is calm and no longer poses a risk to themselves or others, the restraints should be removed promptly. Choice B Reason: Ensuring that the provider has signed a prescription for restraints within 48 hr is incorrect. Restraints should never be applied without a proper prescription or order from a qualified healthcare provider. The provider's order should be obtained before applying restraints, not within 48 hours afterward. Choice C Reason: Offering the client, a nutritious snack every 4 hr is unrelated to the use of physical restraints and should not be the nurse's priority in this situation. The focus should be on ensuring the client's safety and addressing their behavior. Choice D Reason: Monitoring the client's range of motion every 60 min is a correct action. When a client is restrained, it's essential to monitor their physical well-being regularly. Monitoring range of motion helps ensure that the restraints are not causing harm or discomfort to the client. The specific time interval for monitoring may vary by facility policy but should be frequent enough to assess the client's condition effectively.