NCLEX PN Practice Questions Practice Question
The nurse is caring for a client who is in restraints due to violent behavior. The client states, 'I am a magician; I can get out of anything. There could be trouble now!' Which of the following actions would be most appropriate for the nurse to take?
Correct Answer: A
Rationale: The client's statement suggests a potential intent to escape restraints, posing a safety risk, so notifying staff for assistance is the priority.
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