A combative adolescent client has been placed in seclusion after all other interventions have failed. Which protocol would apply in this situation?

1. The physician or other licensed independent practitioner must reissue a new order for restraints every 24 hours.
2. The physician or other licensed independent practitioner must reissue a new order for restraints every 8 hours.
3. The physician or other licensed independent practitioner must reissue a new order for restraints every 3 to 4 hours.
4. The physician or other licensed independent practitioner must reissue a new order for restraints every 1 to 2 hours.


4
Rationale: The physician or other licensed independent practitioner must reissue a new order for restraints every 4 hours for adults and every 1 to 2 hours for children and adolescents. Restraints should be used as a last resort, after all other interventions have been unsuccessful, and the client is clearly at risk of harm to self or others.

Nursing

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A nurse is caring for a despondent young female patient with an SCI at C5 . The patient verbalizes concern regarding sexual dysfunction. What should the nurse assure this patient she can still experience? (Select all that apply.)

a. Vaginal sensation b. Vaginal orgasm c. Normal menses d. Intercourse e. Children

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The patient decides to discontinue standard medical treatment for diabetes mellitus and to rely on diet and herbal medications for blood sugar control. Which statement, made by the nurse, is most appropriate?

1. You are an adult and can do anything you want to do. 2. Don't you know that you are gambling with your health? 3. Why did you decide to make this change? 4. We need to talk about how medications work to control diabetes mellitus.

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The nurse understands that congenital heart defects are classified relative to hemodynamics. These classifications are: (Select all that apply.)

a. Defects with increased pulmonary blood flow b. Defects with decreased pulmonary blood flow c. Obstructive defects d. Defects with cyanosis e. Mixed defects

Nursing

The nurse is assessing a patient who is malnourished and has a history of poor nutrition. The patient reports difficulty seeing at night. This patient is likely to be deficient in which fat-soluble vitamin?

A)  A (retinol) B)  D C)  E (alpha-tocopherol) D)  K

Nursing