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 C
Explanation
A. Documentation for a mental health client is a defined process based on hospital-specific requirements which highlights client care. While hospitals have policies, documentation must follow legal and ethical guidelines beyond just facility rules.
B. Documentation for a mental health client is focused on the client’s diagnosis, reason for medications, plan of care, and client progression. Documentation includes more than just diagnosis and medication, such as behavior observations, interventions, and responses.
C. Documentation for mental health clients provides a record of the nurse’s awareness of client behaviors, mental status, interventions, and client response. Comprehensive mental health documentation includes behaviors, mental status, interventions, and outcomes.
D. Documentation for a mental health client outlines the client’s therapies, treatments, and needs for discharge planning. This is part of the documentation but does not capture all aspects of mental health nursing records.
Correct Answer is D
Explanation
A. Orientation phase : The orientation phase is when trust begins to form but is not yet solidified.
B. Identification phase: During this phase, the client begins to work with the nurse but has not yet fully accepted interventions.
C. Resolution phase: This phase is the termination of the nurse-client relationship, where trust has already been established.
D. Working phase: The working phase is when trust is fully developed, and the client actively engages in the care process.
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