A newly licensed nurse is applying prescribed wrist restraints on a client. Which of the following actions should the nurse take?
Anticipate removing the restraints every 4 hours.
Secure the restraints to the lowest bar of the side rail.
Secure the restraints using a quick-release tie.
Ensure four fingers fit under the restraints to prevent constriction.
The Correct Answer is C
Choice A reason:
Anticipating removing the restraints every 4 hours is not the best practice. Restraints should be checked frequently, typically every 2 hours, to assess the client’s circulation, skin integrity, and need for continued restraint. The goal is to use restraints for the shortest duration possible.
Choice B reason:
Securing the restraints to the lowest bar of the side rail is incorrect. Restraints should be secured to a part of the bed frame that moves with the client, not to the side rail, to prevent injury and ensure the client’s safety.
Choice C reason:
Securing the restraints using a quick-release tie is the correct action. This ensures that the restraints can be quickly and easily removed in case of an emergency, prioritizing the client’s safety.
Choice D reason:
Ensuring four fingers fit under the restraints to prevent constriction is not accurate. The correct practice is to ensure that two fingers can fit between the restraint and the client’s skin to prevent constriction and ensure proper circulation.
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Correct Answer is C
Explanation
Choice A reason:
Schizophrenia is rarely diagnosed in preschool-aged children. Early-onset schizophrenia can occur, but it is extremely uncommon in this age group.
Choice B reason:
While schizophrenia can develop in school-age children, it is still relatively rare. The typical age of onset is later, during adolescence or young adulthood.
Choice C reason:
Young adulthood is the most common age group for the onset of schizophrenia. Symptoms often begin to appear in late adolescence to early adulthood, typically between the ages of 16 and 30.
Choice D reason:
Schizophrenia is not typically diagnosed in older adulthood. While older adults can experience symptoms of schizophrenia, the onset of the disorder usually occurs much earlier in life.
Correct Answer is D
Explanation
Choice A reason:
Developmental theories focus on the progression of human growth and development through various stages of life. While these theories are important in understanding patient behavior and needs, they do not directly relate to the implementation of a privilege system in an inpatient unit. Privilege systems are more aligned with behavioral theories, which emphasize the modification of behavior through reinforcement and consequences.
Choice B reason:
Humanistic theories emphasize the individual’s capacity for self-actualization and personal growth. These theories focus on the holistic development of the person and the importance of empathy and unconditional positive regard in therapeutic relationships. Although humanistic approaches are valuable in mental health care, they do not specifically address the structured reinforcement strategies used in privilege systems.
Choice C reason:
Cognitive theories focus on the role of thought processes in influencing emotions and behaviors. These theories are crucial in understanding and treating mental health conditions, particularly through cognitive-behavioral therapy (CBT). However, the privilege system, which relies on tangible rewards and consequences to shape behavior, is more closely related to behavioral theories rather than cognitive ones.
Choice D reason:
Behavioral theories are directly related to the use of a privilege system. These theories emphasize the use of reinforcement and punishment to modify behavior. In an inpatient setting, a privilege system is used to encourage desirable behaviors by providing rewards (privileges) and discouraging undesirable behaviors through the removal of privileges. This approach is grounded in the principles of operant conditioning, a key concept in behavioral theories.