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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: In ESRD, anuria means no urine output, so excess fluid accumulates in the body, increasing intravascular volume. This can cause hypertension, pulmonary edema, and respiratory distress. Educating the client about these risks emphasizes the importance of fluid restrictions to prevent life-threatening complications between dialysis sessions, addressing their frustration accurately.
Choice B reason: Advising increased fluid intake is incorrect for anuric ESRD patients, as their kidneys cannot excrete fluid. This would exacerbate fluid overload, leading to hypertension, heart failure, or pulmonary edema. Hydration is managed through dialysis, not increased oral intake, which could overwhelm the body’s limited fluid-handling capacity.
Choice C reason: Stating that fluid intake is unrestricted with dialysis is incorrect. Even with regular dialysis, excessive fluid intake between sessions can lead to overload, causing hypertension or pulmonary edema. Dialysis removes a limited amount of fluid per session, requiring strict restrictions to maintain safe fluid balance and prevent complications.
Choice D reason: While potassium and phosphorus restrictions are critical in ESRD to prevent hyperkalemia and hyperphosphatemia, the client’s question focuses on fluid restrictions. This response does not address fluid overload risks like hypertension or pulmonary edema, which are direct consequences of excessive fluid intake in anuric patients, making it irrelevant to the query.
Correct Answer is A
Explanation
Choice A reason: HIPAA requires client consent to disclose protected health information, like psychological evaluations, to third parties such as employers. This response upholds confidentiality laws, ensuring the client’s privacy is protected while clearly communicating the legal process for information release, making it the most appropriate and compliant action.
Choice B reason: Forwarding the call to the doctor delays the response and does not directly address the confidentiality requirement. While the doctor may handle consent, the nurse can directly inform the employer about the need for signed consent, maintaining clarity and legal compliance in protecting patient privacy.
Choice C reason: Refusing to confirm or deny the client’s presence is overly restrictive and not necessary for an employer’s request. It avoids addressing the consent process, which is the legal requirement for releasing information, making it less direct and potentially confusing in this context.
Choice D reason: Stating that information cannot be given is accurate but incomplete, as it does not explain the consent process. Providing a clear path (obtaining signed consent) ensures compliance with confidentiality laws while addressing the employer’s request, making this response less precise than option a).
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