The nurse is providing care to a client who is diagnosed with paranoid schizophrenia. The client is threatening the staff and believes the staff is trying to harm him
When the nurse enters the client's room, the client is agitated, and attempts to slap the nurse. The nurse gets assistance from other staff members and restrains the client. Which nursing action is the priority at this time?
1. Requesting a psychiatric referral
2. Notifying the health care provider of the need to see the client within the hour
3. Padding the side rails
4. Obtaining consent from the client for use of restraints
Correct Answer: 2
After applying restraints, the client must be seen by the health care provider within an hour, and an order should be obtained. A psychiatric referral might be required, but it is not the priority action. There is no need to pad the side rails. Consent from the client is not required if the restraints are applied to prevent harm to the client or others.
You might also like to view...
The nurse is educating high school students about puberty. What will the nurse indicate regulates the production of sperm and secretion hormones?
a. Testes b. Vas deferens c. Ejaculatory ducts d. Prostate gland
_______________ _________and personal characteristics determine health behavior in individuals and families. More than half of all health problems are the result of behavior and lifestyle
ANS:
A patient is admitted to the neurologic ICU with a suspected diffuse axonal injury. What would be the primary neuroimaging diagnostic tool used on this patient to evaluate the brain structure?
A) MRI B) PET scan C) X-ray D) Ultrasound
A patient is diagnosed with a disorder of autocrine regulation. Which explanation of this condition would the nurse provide to the patient and family?
1. "The cells that produce some of your body's hormones are not recognizing that sufficient hormone is present.". 2. "Your blood is not circulating hormones well enough to get them to the places they need to be in your body.". 3. "Some of your hormones are not able to travel to their neighboring cells to do their work.". 4. "Your nervous system is not working with your endocrine system correctly.".