A nurse is discussing the use of mechanical restraints with a newly licensed nurse. Which of the following situations should the nurse include as an indication for placing a client in mechanical restraints?

Self-destructive behavior despite alternative interventions

Discipline for throwing objects at staff

Punishment for verbally abusing other clients

Coercion to take prescribed medications

Answer and Explanation

The Correct Answer is A

A. Self-destructive behavior despite alternative interventions: Mechanical restraints may be considered when a client poses an immediate risk of harm to themselves, and alternative interventions have been ineffective or are not feasible.

B. Discipline for throwing objects at staff: Mechanical restraints are not appropriate as a form of discipline. Restraints should only be used when there is an imminent risk of harm to the client or others.

C. Punishment for verbally abusing other clients: The use of restraints as a form of punishment is not ethical or appropriate. Restraints should be employed solely to prevent harm, not as a disciplinary measure.

D. Coercion to take prescribed medications: Coercion to take medications is not a valid reason for using mechanical restraints. Alternative approaches, such as therapeutic communication or discussing the need for medications with the client, should be explored.

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Correct Answer is C

Explanation

A. Teaching clients about their illness: This function is within the scope of practice for both registered nurses and advanced practice psychiatric nurses. Registered nurses often provide education to clients about their illnesses, medications, and overall care.

B. Maintaining safety on the milieu: Both registered nurses and advanced practice psychiatric nurses are responsible for maintaining safety on the milieu. This includes monitoring the environment, assessing potential risks, and intervening to ensure the safety of clients and staff.

C. Prescribing medications: This function is exclusive to advanced practice psychiatric nurses, such as psychiatric nurse practitioners. Registered nurses do not have the authority to prescribe medications. Advanced practice psychiatric nurses receive additional education and training that allows them to prescribe medications as part of their role.

D. Administering medications: Registered nurses, including those specializing in psychiatric nursing, are authorized to administer medications. This is a common nursing function and does not require advanced practice authorization.

A. Use clear, calm statements and a confident physical stance B. Provide objective evidence that violence is unwarranted. C. Empathize with the clients paranoid perceptions. D. initially restrain the client to maintain safety

Correct Answer is A

Explanation

A. Use clear, calm statements and a confident physical stance:

This is the most appropriate choice. Clear and calm communication, along with a confident physical stance, can help to de-escalate the situation. It demonstrates assertiveness and can potentially prevent further escalation of violence.

B. Provide objective evidence that violence is unwarranted:

While providing objective evidence may be helpful in some situations, individuals with paranoid personality disorder may not respond well to attempts to prove that their perceptions are unwarranted. It could potentially escalate the situation.

C. Empathize with the client's paranoid perceptions:

While empathy is important in communication, empathizing with paranoid perceptions in a way that validates or reinforces them may not be the best approach. It could inadvertently validate the client's distorted thoughts and potentially escalate the situation.

D. Initially restrain the client to maintain safety:

Physical restraint should be a last resort and used only when the safety of the client or others is at immediate risk. Initial restraint can escalate aggression and may not be the most appropriate intervention in the early stages of a violent episode.

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A nurse is discussing the use of mechanical restraints with a newly licensed nurse. Which of the following situations should the nurse include as an indication for placing a client in mechanical restraints?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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