A nurse is assisting in the care of a client who is in restraints following an episode of violence. Which of the following information should the nurse document in the client's medical record? (Select all that apply.)

Providing opportunities for nutrition and toileting

Observing range of motion of client's extremities

Observation of the client once per hour

Attempts at less restrictive interventions

Names of staff members caring for the client

Answer and Explanation

Correct Answer : A,B,D,E

A.   It is essential to document the times when the client was offered opportunities for nutrition and toileting while in restraints. This includes offering food and fluids at regular intervals and assisting the client with toileting needs as required. Documentation ensures that these basic needs are met despite the restraint status.
B.   Documenting observations of the client's range of motion helps monitor for any signs of discomfort, circulation issues, or injury related to being in restraints. This documentation is crucial for ensuring the client's safety and well-being during restraint use.
C.   observation of the client should be conducted more frequently than once per hour, especially after an episode of violence, to closely monitor the client's condition and response to the restraints.
D.   Documenting attempts at less restrictive interventions shows that the healthcare team is actively working to minimize the use of restraints whenever possible. This might include attempts to de-escalate the client, use of medications, or other interventions aimed at reducing agitation or violence without resorting to physical restraints.
E.   It is important to document the names of staff members who are directly involved in the care of a restrained client. This ensures accountability and provides a clear record of who has been caring for the client during their restraint period.

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Correct Answer is A

Explanation

A. Dual diagnosis treatment programs are specifically designed for individuals who have both a mental health disorder (such as ASPD) and a substance use disorder (alcohol dependency in this case). These programs integrate treatment approaches that address both conditions concurrently. They typically involve a combination of medication management, psychotherapy, and support groups tailored to dual diagnosis clients. Encouraging the client to participate in a dual diagnosis treatment group can help address the complex interplay between ASPD and alcohol dependency.
B. Codependency support groups focus on relationships where one person may enable or support dysfunctional behavior in another person. While relevant in certain contexts, codependency support groups may not directly address the primary issues of ASPD and alcohol dependency. Therefore, this option is less appropriate compared to dual diagnosis treatment for this client.
C. Psychodrama is a form of therapy where clients act out real-life situations to explore and gain insights into their feelings, behaviors, and relationships. While psychodrama can be beneficial for emotional expression and role-playing, it may not directly target the core symptoms and challenges of ASPD and alcohol dependency. Therefore, it may not be the most effective intervention for this client compared to dual diagnosis treatment.
D. Crisis intervention focuses on immediate stabilization and support during a mental health crisis or acute episode. While crisis intervention may be necessary at times, it is not a comprehensive treatment approach for ASPD and alcohol dependency. Long-term management and therapeutic interventions, such as dual diagnosis treatment, are typically needed to address these chronic conditions effectively.

A. "The PSDA becomes applicable when a client reaches 65 years of age." B. "A witness is legally required to sign a client's living will." C. "Advance directives do not apply to clients receiving mental health care." D. "A client can verbally designate a durable power of attorney."

Correct Answer is D

Explanation

A. The PSDA applies to all adult clients regardless of age. It ensures that adults have the right to make decisions about their medical care, including the right to accept or refuse treatment, regardless of whether they are elderly or not. Age is not a factor in the applicability of the PSDA.
B. While it's common for a living will to be witnessed, it is not a legal requirement under the PSDA.
C. Advance directives are applicable to all clients, including those receiving mental health care.
D. The Patient Self-Determination Act (PSDA) ensures that adult patients are informed about their rights to make decisions regarding their medical care, including the right to accept or refuse treatment and to prepare an advance directive.

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A nurse is assisting in the care of a client who is in restraints following an episode of violence. Which of the following information should the nurse document in the client's medical record? (Select all that apply.)

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Correct Answer is D

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