A nurse in a mental health unit is discussing restraints and seclusion with a group of newly hired nurses. At which of the following times should a nurse discuss the restraint and seclusion policy with a client?
Upon admission
While administering chemical or physical restraints
When a client becomes agitated
During debriefing after restraint removal
The Correct Answer is A
A. Upon admission: The best time to discuss policies on restraints and seclusion is at admission, when clients are calm and able to understand their rights.
B. While administering chemical or physical restraints : Explaining the policy during restraint use can increase client distress and agitation.
C. When a client becomes agitated: Discussing restraint policies while a client is already agitated is ineffective and could escalate distress.
D. During debriefing after restraint removal : While debriefing is important, waiting until after restraints are removed does not allow for proactive education.
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Related Questions
Correct Answer is D
Explanation
A. Interrupt the client's statement to clarify thoughts or ideas. Interrupting can make the client feel unheard and disrupt the flow of conversation.
B. Show emotion when a client is disclosing sensitive information. While empathy is important, the nurse should remain professional and composed to provide objective support.
C. Keep direct eye contact to a minimum. Avoiding eye contact may appear disinterested or disengaged.
D. Avoid looking at other clients on the unit. Maintaining focus on the client demonstrates active listening, engagement, and respect.
Correct Answer is A
Explanation
A. The client must be calm and cooperative. Restraints should be removed as soon as the client is calm and no longer poses a threat to themselves or others. Continued use without justification can be considered unethical and unlawful.
B. The client must verbalize remorse for their behavior. Remorse is not a requirement for restraint removal. Some clients may lack insight into their actions due to mental illness or cognitive impairment. The focus should be on safety, not forced expressions of regret.
C. The client only verbalizes anger toward the staff. Expressing anger alone is not a justification for continued restraint. As long as the client is not aggressive or violent, they should not remain restrained.
D. The provider who prescribed the restraints must be present to assess the client before the restraints can be removed. Nurses can remove restraints without the provider physically present if the client meets the criteria for release. However, they must document the assessment and notify the provider.
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