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    Nurs 100 Fundamentals Proctored Exam

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    Question: 1 of 78Nurs 100 fundamentals proctored exam
    The nurse is caring for a hospitalized patient. Which behavior alerts the nurse to consider the temporary need for restraint?
    Explanation
    A. The patient does not sleep and continues to ask for items: Though disruptive, this behavior doesn’t pose imminent risk of self‑harm or interference with necessary treatment; less restrictive measures such as redirection or adjusting environment should be tried first B. The patient continues to remove the nasogastric tube: This is exactly the scenario in which non‑violent, non‑self‑destructive restraints may be appropriate-to prevent disruption of essential medical treatments or self‑injury, after alternatives fail. C. The patient refuses to call for help to go to the bathroom: This reflects autonomy and reluctance to ask for help; it doesn’t involve imminent risk or removal of essential devices, so other interventions (education, encouragement) are more appropriate D. The patient gets confused regarding the time at night: Mild disorientation alone-not associated with disruptive or dangerous behavior-is better addressed with reorientation and staffing strategies first.
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