Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
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?.
A. Document the client's behavior in the medical record every 1 hr
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.
B. Provide range-of-motion exercises to all extremities every 2 hr.
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.
C. Request the provider renew the prescription in 24 hr.
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.
D. Keep staff interactions with the client to a minimum.
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.
This question is an excerpt from Nurse Dive's nursing test bank - ATI PN Mental health DEC 2023 Proctored Exam. Take the full exam now
Full Explanation
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.
Similar Questions
A nurse is caring for a client who becomes extremely agitated and asks if they can go to a separate room to be alone for an hour.
The nurse should document which of the following de-escalation techniques in the client's medical record?.
A. Timeout
A rationale: A timeout is a de-escalation technique where the client is allowed to spend time alone in a safe environment to regain control.
B. Restraint.
B rationale: Restraint is not a de-escalation technique. It is a last resort measure used when other methods have failed and the client is a danger to themselves or others.
C. Diversion.
C rationale: Diversion is a technique used to distract the client from a stressful situation, not a de-escalation technique.
D. Therapeutic hold.
D rationale: A therapeutic hold is a type of physical restraint, not a de-escalation technique.
Full Explanation
Choice A rationale:
A timeout is a de-escalation technique where the client is allowed to spend time alone in a safe environment to regain control.
Choice B rationale:
Restraint is not a de-escalation technique. It is a last resort measure used when other methods have failed and the client is a danger to themselves or others.
Choice C rationale:
Diversion is a technique used to distract the client from a stressful situation, not a de-escalation technique.
Choice D rationale:
A therapeutic hold is a type of physical restraint, not a de-escalation technique.
A nurse is reinforcing teaching with a client who started taking haloperidol decanoate 125 mg IM 1 month ago.
Which of the following statements by the client should the nurse address?.
A. "I check my blood pressure once a week.”.
A rationale: Checking blood pressure once a week is a good practice, especially for clients on medications that can affect blood pressure.
B. "I chew sugar-free gum several times daily.”.
B rationale: Chewing sugar-free gum several times daily is not harmful and can help with dry mouth, a common side effect of haloperidol.
C. "I haven't had a drink of alcohol since I started taking these injections.”.
C rationale: Avoiding alcohol while taking haloperidol is recommended as alcohol can increase the side effects of the medication.
D. "I spend several hours a day outside gardening when it's sunny.”. .
D rationale: Spending several hours a day outside gardening when it’s sunny can lead to a condition called photosensitivity, a side effect of haloperidol. The client should be advised to wear protective clothing and sunscreen when outside.
Full Explanation
Choice A rationale:
Checking blood pressure once a week is a good practice, especially for clients on medications that can affect blood pressure.
Choice B rationale:
Chewing sugar-free gum several times daily is not harmful and can help with dry mouth, a common side effect of haloperidol.
Choice C rationale:
Avoiding alcohol while taking haloperidol is recommended as alcohol can increase the side effects of the medication.
Choice D rationale:
Spending several hours a day outside gardening when it’s sunny can lead to a condition called photosensitivity, a side effect of haloperidol. The client should be advised to wear protective clothing and sunscreen when outside.
A nurse is caring for a client who has dementia and is experiencing an increased number of falls.
Which of the following actions should the nurse take?.
A. Lower the window shade in the client's room.
A rationale: Lowering the window shade in the client’s room does not directly contribute to fall prevention. It might even increase the risk if it makes the room darker and the client can’t see clearly.
B. Obtain a PRN prescription for a vest restraint.
B rationale: Using a vest restraint is not the best option. Restraints should be used as a last resort, and only if less restrictive interventions have been ineffective.
C. Place the client in a room close to the nurses' station.
C rationale: Placing the client in a room close to the nurses’ station allows for more frequent observation and quicker response if the client needs assistance, reducing the risk of falls.
D. Request a consult with recreational therapy.
D rationale: While recreational therapy can be beneficial for clients with dementia, it does not directly address the issue of fall prevention.
Full Explanation
Choice A rationale:
Lowering the window shade in the client’s room does not directly contribute to fall prevention. It might even increase the risk if it makes the room darker and the client can’t see clearly.
Choice B rationale:
Using a vest restraint is not the best option. Restraints should be used as a last resort, and only if less restrictive interventions have been ineffective.
Choice C rationale:
Placing the client in a room close to the nurses’ station allows for more frequent observation and quicker response if the client needs assistance, reducing the risk of falls.
Choice D rationale:
While recreational therapy can be beneficial for clients with dementia, it does not directly address the issue of fall prevention.