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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Using authoritative leadership to help clients learn to conform to societal norms: Authoritative leadership may be perceived as controlling and is unlikely to be effective with clients diagnosed with borderline personality disorder. It can lead to resistance and difficulties in building a therapeutic alliance.
B. Being firm, consistent, and empathetic, while addressing specific client behaviors: This approach is most appropriate. Clients with borderline personality disorder often benefit from clear and consistent boundaries, along with empathy from the nurse. Addressing specific behaviors helps establish a structured and safe therapeutic environment.
C. Promoting client expression by implementing laissez-faire leadership: Laissez-faire leadership, characterized by minimal interference or direction, is generally not suitable for clients with borderline personality disorder. They may struggle with emotional dysregulation and benefit from a more structured and supportive approach.
D. Overlooking inappropriate behaviors to avoid promoting secondary gains: Overlooking inappropriate behaviors may reinforce maladaptive patterns and hinder progress in therapy. It is essential to address and work through specific behaviors while maintaining empathy and consistency.
Correct Answer is D
Explanation
A. Provide client with high-calorie finger foods throughout the day:
While providing high-calorie finger foods may increase caloric intake, it may not be the most effective strategy for a specific weight gain goal. It's essential to encourage a balanced and varied diet.
B. Teach the importance of a varied diet to meet nutritional needs:
This is a good general approach to promote overall nutritional health, but it may not be specific enough to address the immediate goal of gaining 2 pounds within a week.
C. Initiate total parenteral nutrition to meet dietary needs:
Total parenteral nutrition is an invasive and aggressive intervention typically reserved for cases where oral or enteral feeding is not possible or insufficient. It is not the first-line approach for someone who can consume food orally.
D. Accompany client to cafeteria to encourage adequate dietary consumption:
This is the most appropriate intervention. Accompanying the client to the cafeteria provides an opportunity for direct encouragement and support during meals. It helps ensure that the client is consuming an adequate amount of food, which is crucial for the goal of gaining 2 pounds within a week.
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