A nurse is planning care for a client who has adjustment disorder following a traumatic below-the-knee amputation. Which of the following actions should the nurse include?

Respect the client's need for social isolation.

Encourage the client's family members to perform the client's ADLS.

Discourage the client from talking about activities he did prior to the amputation.

Determine the client's stage of grief.

Answer and Explanation

The Correct Answer is D

A. Respect the client's need for social isolation:
While it's important to respect the client's need for moments of solitude and privacy, complete social isolation can lead to feelings of loneliness and exacerbate depressive symptoms. Balance is key; the nurse should encourage social interactions and support while respecting the client's need for personal space and alone time.

B. Encourage the client's family members to perform the client's ADLs:
Encouraging the client's family members to take over all activities of daily living (ADLs) can strip the client of their independence and self-efficacy. Instead, the nurse should support the client in actively participating in their self-care activities to the extent they are able. This promotes a sense of control and empowerment during a challenging time.

C. Discourage the client from talking about activities he did prior to the amputation:
Discouraging the client from discussing their life before the amputation can hinder the process of accepting the loss. Allowing the client to talk about their past experiences, activities, and memories can be therapeutic. It helps them process the grief associated with the amputation and allows for a healthy expression of emotions.

D. Determine the client's stage of grief:
Understanding the client's stage of grief is crucial. Grieving is a natural and individual process, and different people progress through stages like denial, anger, bargaining, depression, and acceptance at their own pace. By identifying the client's current stage of grief, the nurse can offer tailored support and interventions, ensuring the client's emotional needs are met effectively.

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Correct Answer is B

Explanation

A. Clients who are involuntarily committed do not maintain access to legal counsel.
This statement is incorrect. Clients who are involuntarily committed generally do have the right to legal counsel. They can challenge their commitment in a court of law, and legal representation is often provided to them if they cannot afford it.

B. Clients must be informed of the risks of treatment.
This statement is correct. Informed consent is a fundamental principle in healthcare, including mental health treatment. Clients have the right to be fully informed about the risks and benefits of any treatment or procedure before giving consent.

C. Clients who have a severe mental illness cannot request a psychiatric advance directive.
This statement is incorrect. Clients with severe mental illness can, and should, create psychiatric advance directives. These directives allow individuals to specify their preferences regarding mental health treatment in advance, ensuring their wishes are respected even if they are not able to communicate them at a later time due to their mental condition.

D. Clients who are violent can refuse chemical restraint.
This statement is generally incorrect. In emergency situations where a client poses an immediate danger to themselves or others, chemical restraint might be administered without the client's consent to ensure safety. However, there are strict guidelines and regulations surrounding the use of chemical restraints, and they should only be used in specific situations and as a last resort. In non-emergency situations, clients generally have the right to refuse any treatment, including chemical restraint, unless it is court-ordered due to their condition posing an imminent risk.

A. Obtain a prescription for restraints on an as-needed basis. B. Have the provider assess the client within 1 hr after applying the restraints. C. Request that the provider renew the prescription for restraints every 8 hr. D. Evaluate the client hourly while the restraints are applied.

Correct Answer is B

Explanation

A. Obtain a prescription for restraints on an as-needed basis:
Restraints should never be used on an as-needed basis without a specific, individualized order from a healthcare provider. Restraints are a significant intervention that should only be used when necessary, and they require a clear prescription outlining the duration, reason, and method of application.

B. Have the provider assess the client within 1 hour after applying the restraints:
This option is the correct choice. It is crucial to involve the healthcare provider promptly after restraints are applied. The provider needs to assess the patient's physical and mental status, and the appropriateness of the restraints, and consider alternatives or modifications to the intervention. Regular assessments ensure the patient's safety and well-being while addressing the initial reason for applying restraints.

C. Request that the provider renew the prescription for restraints every 8 hours:
Restraining a patient every 8 hours without ongoing assessment and a clear clinical rationale is inappropriate and goes against best practices. Restraints should only be used when absolutely necessary and should be reevaluated frequently. Requesting a renewal on a fixed schedule without considering the patient's changing condition is not a safe or ethical approach.

D. Evaluate the client hourly while the restraints are applied:
While regular monitoring of a patient in restraints is essential, evaluating the patient every hour might not be sufficient, especially in the early stages after the application of restraints. The patient should be continuously monitored, with assessments conducted more frequently, especially immediately after applying the restraints, to ensure their safety and well-being.

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