A client receives a court order for commitment. Which concept exemplifies a “least restrictive environment”?

Admission of client to a locked inpatient psychiatric unit

Placement of client in a secured padded room in response to threats of self-harm

Involuntary commitment to an outpatient community mental health center

Medication administration for sedation so the client cannot get out of bed

Answer and Explanation

The Correct Answer is C

Choice A reason:
Admission to a locked inpatient psychiatric unit is a more restrictive environment. While necessary for some clients, it limits their freedom and autonomy. The least restrictive environment principle seeks to avoid such settings unless absolutely necessary.

Choice B reason:
Placement in a secured padded room is highly restrictive and typically used only in extreme cases where the client poses an immediate danger to themselves or others. This setting is far from the least restrictive environment.

Choice C reason:
Involuntary commitment to an outpatient community mental health center represents a less restrictive environment. It allows the client to receive necessary treatment and support while remaining in the community, maintaining a higher level of independence and normalcy.

Choice D reason:
Medication administration for sedation to the point where the client cannot get out of bed is a highly restrictive intervention. It significantly limits the client’s autonomy and is not aligned with the principle of providing care in the least restrictive environment.

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Correct Answer is C

Explanation

Choice A reason:
Putting the client in a quiet room can help reduce external stimuli and may be beneficial in managing anxiety. However, it does not address the immediate need for support and reassurance. The presence of a nurse can provide a sense of safety and help the client feel more secure during a highly anxious state.
Choice B reason:
Teaching the client deep breathing techniques is an effective strategy for managing anxiety. However, in the immediate aftermath of a traumatic event, the client may not be able to focus on learning new techniques. Providing immediate support and reassurance is more critical at this stage.
Choice C reason:
Remaining with the client is the most appropriate immediate intervention. The nurse’s presence can provide comfort, reassurance, and a sense of safety, which are crucial in managing acute anxiety. This approach helps to stabilize the client and allows for further assessment and intervention once the client is calmer.
Choice D reason:
Encouraging the client to talk about their feelings and concerns is an important part of anxiety management, but it may not be the best immediate intervention in a severe state of anxiety. Initially, the client may need more direct support and reassurance before they are able to articulate their feelings effectively. Once the client is calmer, discussing their feelings can be beneficial.

A. PREDICTABLE SOCIAL ENVIRONMENT B. ADEQUATE FOOD C. POSITIVE SELF-IMAGE D. ACCEPTANCE FROM FAMILY

Correct Answer is B

Explanation

Choice A reason:
A predictable social environment is important for providing stability and security, which can contribute to a client’s overall well-being. However, according to Maslow’s hierarchy of needs, physiological needs such as food and water must be met before higher-level needs like social stability can be addressed. Therefore, while important, a predictable social environment is not the immediate priority.
Choice B reason:
Adequate food is a fundamental physiological need according to Maslow’s hierarchy of needs. Physiological needs are the most basic and must be satisfied before an individual can focus on higher-level needs such as safety, love, and self-esteem. Ensuring that the client has adequate food is essential for their survival and overall health, making it the top priority in the plan of care.
Choice C reason:
A positive self-image is associated with self-esteem needs, which are higher up in Maslow’s hierarchy. While fostering a positive self-image is important for a client’s mental health and well-being, it cannot be effectively addressed until basic physiological needs are met. Therefore, it is not the immediate priority in the plan of care.
Choice D reason:
Acceptance from family relates to the need for love and belonging, which is also higher up in Maslow’s hierarchy. While family acceptance is crucial for emotional support and social well-being, it is not as immediate a priority as ensuring that the client’s basic physiological needs, such as adequate food, are met first.

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A client receives a court order for commitment. Which concept exemplifies a “least restrictive environment”?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A woman comes into the Emergency Department in a severe state of anxiety following a car accident. The appropriate nursing intervention is to:

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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A woman comes into the Emergency Department in a severe state of anxiety following a car accident. The appropriate nursing intervention is to:

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