A nurse is performing safety assessments on a client in mechanical restraints as required by policy. Which action by the nurse demonstrates the ethical principle of nonmaleficence?

Releasing the client when stated behavioral control is achieved

Explaining the behavioral requirements for release of restraint to the client

Applying restraints based solely on assessment findings and not on attitude toward the client

Assuring that the restraints are not causing injury to the client

Answer and Explanation

The Correct Answer is D

Choice A reason: Releasing the client when behavioral control is achieved aligns with autonomy and beneficence, not nonmaleficence. While it benefits the client, it does not directly address harm prevention, which is the core of nonmaleficence. The focus is on restoring freedom, not specifically ensuring no physical harm during restraint use.

Choice B reason: Explaining release requirements promotes understanding and autonomy but does not directly prevent harm, the focus of nonmaleficence. It supports therapeutic communication but does not address the physical safety risks of restraints, such as skin breakdown or circulation issues, making it less relevant to this principle.

Choice C reason: Applying restraints based on assessment, not attitude, ensures objectivity, aligning with justice and fairness. While this prevents inappropriate restraint use, it is less directly tied to nonmaleficence, which focuses on avoiding harm like injury during restraint application, making it a secondary consideration in this context.

Choice D reason: Assuring restraints do not cause injury directly upholds nonmaleficence, the ethical principle of avoiding harm. Regular checks for skin breakdown, circulation impairment, or nerve damage prevent physical harm, ensuring safety during restraint use, making this action the most aligned with nonmaleficence in a restrained client.

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Correct Answer is C

Explanation

Choice A reason: Neighborhood watch programs enhance community safety but do not directly address mental health needs. They lack therapeutic components to manage symptoms or prevent decompensation, which are critical for preventing readmission in clients with mental health disorders, making this factor less relevant to sustained community stability.

Choice B reason: Taking meals at a food bank addresses nutritional needs but does not directly support mental health stability. While nutrition is important, it does not provide the therapeutic interventions or coping strategies needed to manage mental health disorders and prevent relapse or hospital readmission.

Choice C reason: Participation in treatment, such as therapy or medication adherence, directly addresses mental health symptoms, improving coping skills and emotional regulation. Consistent treatment reduces relapse risk, enhances stability, and supports community integration, making it the most effective factor for preventing readmission in clients with mental health disorders.

Choice D reason: A safe living environment reduces stress and safety risks but is secondary to active treatment. Without ongoing therapy or medication, environmental safety alone cannot manage symptoms or prevent decompensation, making it less critical than treatment participation for maintaining community stability and avoiding readmission.

A. A calm expression means that the patient is experiencing low levels of anxiety B. Eye contact is a reliable measure of the patient’s degree of attentiveness and engagement C. The meaning of nonverbal communication varies with cultural and individual differences D. Patients respond more consistently to therapeutic touch than to verbal interaction

Correct Answer is C

Explanation

Choice A reason: A calm expression does not reliably indicate low anxiety, as individuals may mask emotions due to cultural norms or coping mechanisms. Nonverbal cues are subjective and context-dependent, and physiological signs like heart rate or cortisol levels are more accurate indicators of anxiety than facial expressions alone.

Choice B reason: Eye contact is not a universal measure of attentiveness, as cultural norms vary (e.g., some cultures avoid eye contact to show respect). Individual factors like anxiety or neurodiversity can also affect eye contact, making it an unreliable indicator of engagement without considering context and patient background.

Choice C reason: Nonverbal communication, such as gestures or expressions, varies widely across cultures and individuals. For example, nodding may signify agreement in one culture but acknowledgment in another. Individual personality or mental health conditions also influence nonverbal cues, making this statement accurate as it accounts for diverse interpretations.

Choice D reason: Therapeutic touch responses vary by individual and cultural preferences, and some patients may find it intrusive or distressing. Verbal interaction is often more consistent in therapeutic settings, as it allows clearer communication of intent. Touch is not universally more effective, making this statement inaccurate.

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A nurse is performing safety assessments on a client in mechanical restraints as required by policy. Which action by the nurse demonstrates the ethical principle of nonmaleficence?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning the discharge of a client with a mental health disorder. Which factor does the nurse identify as the best chance for the client to remain in the community without readmission?

Correct Answer is C

Explanation

Which statement about nonverbal communication is accurate?

Correct Answer is C

Explanation

A nurse and client are engaged in a discussion. The client says, “I feel really close to you. You are my only true friend.” Which response by the nurse would be most therapeutic?

A client diagnosed with end-stage kidney injury receives continuous ambulatory peritoneal dialysis (CAPD). The nurse observes that the dialysate drainage fluid is cloudy. What is the priority intervention?

The nurse asks the client, “What was it like for you when you first realized you had no place to go?” The client looks down and pauses for quite some time. Which action by the nurse is most therapeutic?

A nurse is assigned to administer oral medications to a client. Which action will the nurse do first if a client refuses to take prescribed oral medications?

An adult client was put in restraints after all other attempts to reduce aggression have failed. Which is required now that restraints have been instituted by the nurse?

The nurse is sitting down with a client to begin a conversation. Which position will the nurse take to convey acceptance of the client?