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 C
Explanation
A. Resolution: The resolution phase occurs at the end of care, focusing on termination and closure, not trust-building.
B. Exploitation: This is not a formal phase of the nurse-client relationship in Peplau’s model; the term is outdated and not appropriate.
C. Orientation: The orientation phase is when the nurse establishes trust and rapport with the client.
D. Identification: The identification phase is when the client begins to recognize the nurse’s role in their care, but trust has already been established.
Correct Answer is A
Explanation
A. Beneficence is the duty to do good and act in the best interest of the client, which includes finding alternatives to restraints that promote dignity.
B. Justice refers to fairness in distributing resources and treatment, which does not directly apply in this scenario.
C. Autonomy involves respecting a client’s right to make decisions, but the decision in this case is made by the nurse.
D. Nonmaleficence is avoiding harm, which is closely related but not the best choice because beneficence goes beyond avoiding harm—it actively promotes the client's well-being.
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