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:
Dependence on parents to participate in the client’s care indicates that the client is not progressing towards independence. Effective in-home mental health care aims to empower clients to manage their own health and reduce reliance on others. Therefore, this response does not demonstrate effective care.
Choice B reason:
A need for continued intensive monitoring in the home suggests that the client’s condition remains unstable and requires constant supervision. Effective care should lead to improved stability and a reduction in the need for intensive monitoring.
Choice C reason:
A decrease in admission frequency to inpatient psychiatric hospitals indicates that the client’s condition is stabilizing and that they are managing their mental health more effectively at home. This outcome demonstrates that the in-home mental health care is effective in reducing the need for hospitalization.
Choice D reason:
A need for crisis intervention services on an ongoing basis suggests that the client continues to experience frequent crises. Effective in-home mental health care should help the client develop coping strategies and support systems to manage their condition, reducing the need for frequent crisis interventions.

A. Place the client in seclusion if visual hallucinations are present. B. Limit the number of questions asked during assessments. C. Use frequent touch to provide client support. D. Directly tell the client that delusions are not real.

Correct Answer is B

Explanation

Choice A reason:
Placing the client in seclusion if visual hallucinations are present is not an appropriate first-line intervention. Seclusion should only be used when the client poses an immediate threat to themselves or others and less restrictive measures have failed. It is important to use the least restrictive interventions to manage symptoms.

Choice B reason:
Limiting the number of questions asked during assessments can help reduce the client’s anxiety and prevent overwhelming them. Clients with schizophrenia may have difficulty processing information and may become more paranoid or distressed with too many questions. This approach helps create a more supportive and manageable environment for the client.

Choice C reason:
Using frequent touch to provide client support is not recommended for clients with paranoid delusions. Physical touch may be misinterpreted as a threat or invasion of personal space, exacerbating the client’s paranoia and anxiety. It is important to respect the client’s boundaries and use other forms of support.

Choice D reason:
Directly telling the client that delusions are not real can be confrontational and may increase the client’s distress. Instead, the nurse should acknowledge the client’s feelings and provide reassurance without directly challenging their beliefs. This approach helps maintain a therapeutic relationship and supports the client’s emotional well-being.

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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 nurse is providing in-home mental health care and determines that the care is effective when the client demonstrates which response?

Correct Answer is C

Explanation

A nurse is developing a plan of care for a newly admitted client who has schizophrenia and experiences frequent hallucinations and paranoid delusions. Which of the following actions should the nurse plan to take?

Correct Answer is B

Explanation

A nurse is reviewing the DSM-5 diagnostic criteria for schizophrenia. Which of the following symptoms must be present for a client to be diagnosed with schizophrenia? (Select all that apply.)

When providing care to a client diagnosed with a mental disorder, the client asks the nurse, “Does mental illness run in your family?” Which response by the nurse would be nontherapeutic?

A nurse is providing education to a group of staff members about schizophrenia. Which of the following age groups should the nurse include as the age when schizophrenia is typically diagnosed?

A nurse is discussing schizophrenia spectrum disorders with a client. The client states, “My friend says that before I started hearing voices, I stopped hanging out with them. Why is that?” Which of the following responses should the nurse make?

A nurse is interviewing a client who is experiencing negative symptoms of psychosis about their family history of schizophrenia. In which of the following phases of the nursing process should this take place?

A nurse is preparing to discharge a client who has been diagnosed with schizophrenia. The client asks, “I am not sure why I need to have a relapse plan.” Which of the following responses should the nurse make?

A nurse manager is discussing suicide with nursing staff. Which of the following should the manager identify as risk factors for suicide? (Select all that apply)