A Client in the Intensive Care Unit Is Combative and Pulling

question 23

Multiple Choice

A client in the intensive care unit is combative and pulling at the endotracheal tube, which must remain in place. After exhausting all alternatives, the nurse applies soft restraints to protect the client's airway. Which action should the nurse take next?

• A)Notify the primary healthcare provider.
• B)Notify the family of the need for restraints.
• C)Reassess the need for the restraints in 8 hours.
• D)Document the application of restraints in the chart.

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Definitions:

Cognitive Theory

A psychological paradigm that emphasizes mental processes such as thinking, memory, and problem-solving as central to understanding behavior.

Cognitive Distortion

Irrational thought patterns that contribute to negative emotions, behaviors, or attitudes, often recognized in cognitive-behavioral therapy.

Dysfunctional Thinking

Patterns of thought that are irrational, negative, and may lead to emotional distress or behavioral problems.

Negative Experiences

Negative experiences are events or situations that have a harmful or unpleasant impact on an individual's psychological or physical well-being.