A mental health nurse is planning care for a group of clients.
Which of the following clients should the nurse identify as having a contraindication for applying restraints?
A client who has Obsessive Compulsive Disorder (OCD) and insists on mopping the floor in the day room.
A client who has a personality disorder and tries to manipulate the staff to gain privileges.
A client who has Bulimia Nervosa and refuses to come to the dining room for meals.
A client who is just recovering from a benzodiazepine overdose.
The Correct Answer is D
Choice A rationale: A client with Obsessive Compulsive Disorder (OCD) who insists on mopping the floor in the day room does not pose a direct threat to themselves or others. OCD is characterized by obsessions (persistent, intrusive
thoughts) and compulsions (repetitive behaviors that the person feels compelled to perform). The act of mopping the floor could be a compulsion for this client. While it may be disruptive or unusual, it is not harmful. Therefore, restraints would not be appropriate in this situation.
Choice B rationale: A client with a personality disorder who tries to manipulate staff to gain privileges can be challenging to manage, but this behavior does not warrant the use of restraints. Personality disorders are characterized by enduring patterns of behavior, cognition, and inner experience that deviate from the expectations of the individual’s culture. These patterns are inflexible and pervasive across many personal and social situations.
While manipulation can be frustrating for staff, it is not a danger to the client or others, and other interventions should be used to manage this behavior.
Choice C rationale: A client with Bulimia Nervosa who refuses to come to the dining room for meals is exhibiting behavior related to their eating disorder, but this does not justify the use of restraints. Bulimia Nervosa is characterized by recurrent episodes of binge eating followed by compensatory behaviors such as vomiting, fasting, or excessive exercise. Refusal to eat in a communal setting like a dining room is not uncommon for individuals with eating disorders. This behavior should be addressed through therapeutic interventions, not restraints.
Choice D rationale: A client who is just recovering from a benzodiazepine overdose is the correct answer. Restraints are contraindicated for this client because they could cause physical harm. After a benzodiazepine overdose, the client may experience symptoms such as drowsiness, confusion, and impaired coordination. Restraints could increase the risk of injury, particularly if the client becomes agitated or tries to remove them. In addition, restraints could potentially interfere with medical treatment for the overdose.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"A"}}
Explanation
The correct answer/s is Choice/s.
Choice A rationale: Mental health support is generally considered a protective factor against suicide. Effective mental health care can help individuals manage their mental health conditions, which can reduce the risk of suicide.
Choice B rationale: Family history, particularly a family history of suicide, is a risk factor for suicide. The client’s mother’s suicide could potentially increase the client’s risk.
Choice C rationale: Good physical health is typically seen as a protective factor against suicide. Serious physical health conditions, including chronic pain, can increase suicide risk, but the client is reported to be in good physical health.
Choice D rationale: Support systems, such as feeling connected to family and community, are protective factors against suicide. They can provide emotional support and help individuals feel less isolated.
Choice E rationale: Alcohol consumption, especially misuse or addiction, is a risk factor for suicide. However, the client has attended rehabilitation and has not used alcohol for the past 4 years, which could be seen as a protective factor.
Choice F rationale: Access to lethal means is a risk factor for suicide. Limiting access to lethal means is a societal protective factor.
Correct Answer is B
Explanation
Choice A rationale:
Judgmental and challenging: Asking "Why did you feel you needed to do that at this time?" implies that the parents' decision may not have been the best one. It puts them on the defensive and could make them feel like they need to justify their actions.
Not empathetic: This response does not acknowledge the parents' feelings of sadness, disappointment, or loss. It focuses on the decision itself rather than on the emotional impact it has had on the family.
Not supportive: The nurse's role is to provide support and understanding, not to the parents' decisions. This response does not offer any emotional support or validation.
Choice B rationale:
Empathetic and validating: This response acknowledges the parents' feelings and shows that the nurse understands how difficult it must have been to cancel their son's baseball registration. It also validates their decision, which can be helpful in coping with difficult situations.
Opens up communication: By expressing empathy, the nurse encourages the parents to share their feelings and experiences. This can help them to process their emotions and feel more supported.
Facilitates understanding: By recognizing the parents' frustration, the nurse can better understand their perspective and provide more tailored support. This can help to strengthen the nurse-client relationship and promote trust.
Choice C rationale:
False hope: While it is possible that the child's condition could improve, it is not realistic to offer false hope to the parents. This response could make it more difficult for them to accept the reality of their child's illness and could lead to disappointment and frustration in the future.
Dismissive of feelings: This response does not acknowledge the parents' current feelings of sadness and loss. It focuses on the future, which can be overwhelming and anxiety-provoking for parents who are facing a terminal illness.
Choice D rationale:
Irrelevant and insensitive: The dangers of baseball are not relevant to the parents' decision to cancel their son's registration. This response is dismissive of their feelings and does not offer any support or understanding.
Potentially offensive: This response could be interpreted as suggesting that the parents are being overprotective or that they are making a decision based on fear rather than on their child's best interests.
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