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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Establishing trust and rapport: Establishing trust happens in the orientation phase, not the working phase.
B. Implementing interventions and treatment plans: The working phase focuses on active interventions, therapy, and progress toward client goals, making it the most intensive phase of the nurse-client relationship.
C. Evaluating the effectiveness of interventions: Evaluation happens in the termination phase, where progress is assessed, and the relationship is closed.
D. Assessing the client's health needs: Assessment occurs in the orientation phase, where the nurse gathers initial data and sets goals.
Correct Answer is C
Explanation
A. Assault is a tort that only occurs if a client is physically harmed. Assault is the threat of harm, not the actual harm. Physical harm would be battery.
B. False imprisonment does not apply to use of chemical restraints. False imprisonment includes the improper use of both physical and chemical restraints if used without medical justification or consent.
C. Negligence is the most common unintentional tort. Negligence occurs when a nurse fails to meet the standard of care, leading to client harm, making it the most common unintentional tort in healthcare.
D. Battery occurs when a person verbally threatens to harm another person. Battery involves actual physical contact without consent, while threats fall under assault.
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