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A nurse is caring for a client who is combative and requires wrist restraints. Which of the following actions should the nurse take?
- A. Use a quick-release tie to restrain the client.
- B. Renew the restraint prescription every 48 hr.
- C. Attach the restraints to the side rail of the client's bed.
- D. Maintain 1 fingerbreadth between the restraint and the client's skin.
Correct Answer: A
Rationale: Using a quick-release tie for restraints ensures that the nurse can quickly and easily release the client in case of an emergency. Quick-release ties are designed to provide safety and convenience, allowing healthcare providers to promptly respond to the client's needs without compromising safety.
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A nurse is collecting data from a client who reports cessation of nicotine use. Which of the following manifestations should the nurse expect? (Select all that apply.)
- A. Weight gain
- B. Difficulty concentrating
- C. Diarrhea
- D. Restlessness
- E. Decreased appetite
Correct Answer: A,B
Rationale: Weight gain is a common manifestation after cessation of nicotine use due to increased appetite and caloric intake. Difficulty concentrating is another common symptom experienced during nicotine withdrawal due to the loss of nicotine's stimulant effects on the brain.
A nurse is assisting with the involuntary admission of a client who has an anxiety disorder and is unable to meet their basic physical needs. Which of the following statements should the nurse make to the client?
- A. You have the right to refuse medications prescribed during your stay.
- B. Your admission status allows you to leave the facility at any time.
- C. Your health care team will review your admission status in 90 days.
- D. You will automatically have a legal guardian appointed during this admission.
Correct Answer: A
Rationale: Clients who are involuntarily admitted to a psychiatric facility retain certain rights, including the right to refuse medications. This is an important part of patient autonomy and informed consent. Even though the client is involuntarily admitted, they must still be provided with information about their treatment options and have the right to make decisions about their medications unless there is a court order stating otherwise.
A nurse is assisting in the care of an adolescent who states
- A. I hate living at home. It's impossible to please my parents. Which of the following responses should the nurse make?
- B. Your parents care for you and want what's best for you.
- C. Let's talk about your relationship with your parents.
- D. Why do you think your parents are hard to please?
- E. Things will get better as time goes on.
Correct Answer: B
Rationale: This response opens up a conversation about the adolescent's feelings and experiences regarding their relationship with their parents. It shows empathy and a willingness to understand the adolescent's perspective, which can help build trust and rapport. By exploring the relationship, the nurse can gather more information and provide appropriate support and guidance.
A nurse is reinforcing teaching with a client who has generalized anxiety disorder and a new prescription for buspirone. Which of the following information should the nurse include?
- A. This medication is known to cause dependence.
- B. Avoid consuming large amounts of leafy, green vegetables while taking this medication.
- C. It can take several weeks before you notice an effect from the medication.
- D. If a dose is missed, you can take the missed dose along with the next scheduled dose.
Correct Answer: C
Rationale: Buspirone typically takes several weeks to achieve its full therapeutic effect. Clients should be advised to continue taking the medication as prescribed and not to expect immediate relief of anxiety symptoms. This information helps set realistic expectations and encourages adherence to the treatment plan.
A nurse in a mental health facility is collecting a blood specimen from a client. The client is hallucinating and states
- A. That looks like a snake, and I won't let it take all of my blood. Which of the following responses should the nurse make?
- B. Your provider requires this blood specimen.
- C. You must be mistaken. Snakes cannot be in the clinic.
- D. I'm using a syringe to obtain your blood, not a snake.
- E. I don't see a snake, but that must be scary for you.
Correct Answer: D
Rationale: Acknowledging the client's hallucination and expressing empathy is the most appropriate response. By saying, 'I don't see a snake, but that must be scary for you,' the nurse acknowledges the client's fear and provides comfort without reinforcing the hallucination. This approach helps build trust and rapport, making it easier to proceed with the necessary procedure while ensuring the client's emotional wellbeing.