A nurse is reviewing treatment alternatives for managing a client's behavior. The nurse should identify that which of the following examples describes the least restrictive alternative?
An adult client is confined with physical restraints after throwing chairs at other clients and staff.
An adolescent is taken to a secure, quiet room after threatening and lashing-out at other clients and staff.
An 8-year-old child is asked to return to their room after yelling at other children during a group therapy session.
An adult client is given clozapine, an antipsychotic medication, after punching a wall with their fist and telling everyone that they intend to hurt them.
The Correct Answer is C
A. An adult client is confined with physical restraints after throwing chairs at other clients and staff. Physical restraints are highly restrictive and should be used as a last resort when safety is at risk.
B. An adolescent is taken to a secure, quiet room after threatening and lashing out at other clients and staff. Seclusion is restrictive but less so than physical restraints; however, other interventions should be attempted first.
C. An 8-year-old child is asked to return to their room after yelling at other children during a group therapy session. This is the least restrictive intervention, as it involves verbal redirection rather than confinement or medication.
D. An adult client is given clozapine, an antipsychotic medication, after punching a wall with their fist and telling everyone that they intend to hurt them. Medication can be restrictive when used for behavior control rather than for medical necessity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "Competency and capacity are often discussed as being the same thing, but they are different." Competency is a legal determination made by a court, while capacity is a clinical assessment made by healthcare providers. Although they are related, they are distinct concepts.
B. "Capacity and competency are the same thing and can be used interchangeably." This is incorrect because capacity refers to a person's ability to make a decision at a specific moment, while competency is a broader legal determination regarding decision-making ability.
C. "A client who has been deemed legally incompetent can provide informed consent for treatment." A legally incompetent client cannot provide informed consent. Instead, a legally designated surrogate (guardian or power of attorney) makes medical decisions on their behalf.
D. "Competency and capacity are rarely a concern when caring for clients who have a mental illness." Mental illness can impact decision-making capacity, making assessments crucial. Competency and capacity evaluations are common in mental health settings, especially for clients with cognitive impairment or psychosis.
Correct Answer is D
Explanation
A. Exploitation phase : This is an outdated term; it refers to a subphase of the working phase, but not specifically to goal-setting after initial goals are met.
B. Termination phase: The termination phase is when the nurse-client relationship ends and final evaluations are made, not when new goals are set.
C. Orientation phase: The orientation phase is when the initial goals and trust are established, not when new goals are set.
D. Working phase: The working phase involves active intervention and goal achievement. When initial goals are met, new ones are set, making this the best answer.
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