A nurse is caring for a client who consumed alcohol 2 days after taking disulfiram. The nurse should monitor the client for which of the following findings?

Choice A reason: Autonomy empowers client decision-making, not truth-telling directly. The nurse’s honesty supports it indirectly, but the act itself aligns more with ethical transparency principles.

Choice B reason: Justice ensures fair treatment, unrelated to disclosing medication effects. Truthful communication addresses individual care, not equitable resource distribution in this scenario.

Choice C reason: Veracity is truthfulness, exemplified by explaining adverse effects accurately. This builds trust and informed consent, a core ethical duty in mental health nursing.

Choice D reason: Beneficence promotes well-being, but truth-telling isn’t inherently beneficent. It’s about honesty, not just benefit, aligning with veracity over doing good in this context.

Choice A reason: Releasing restraints every 4 hours lacks context; policy requires 2-hour checks with release if safe. Scientifically, this risks neglect, as frequent assessment ensures circulation and safety, making it less precise than behavior documentation.

Choice B reason: Hourly checks are good but not the action specified; 15-minute intervals are standard for restraints. Scientifically, this underestimates risk monitoring needs, as behavior justification is a legal and clinical priority over timing alone.

Choice C reason: Client consent isn’t required for restraints in emergencies; provider orders suffice. Scientifically, imminent harm overrides autonomy, and consent isn’t feasible mid-crisis, making this impractical and misaligned with restraint protocols.

Choice D reason: Documenting behavior justifies restraints, ensuring legal and ethical use for safety. Scientifically, this aligns with standards, as specific actions (e.g., aggression) validate intervention, providing a clinical basis critical for care continuity and review.