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 B
Explanation
A. "Therapeutic communication is important for nurse-to-nurse interactions, but not as critical for nurse-to-client interactions." Therapeutic communication is essential in nurse-client interactions, as it builds trust, fosters emotional well-being, and enhances care outcomes.
B. "Therapeutic communication is a key component of mental health nursing and the therapeutic nurse-client relationship that improves the emotional well-being of the client." Therapeutic communication actively supports mental health treatment by ensuring clients feel heard, validated, and understood, which is crucial in emotional and psychological care.
C. "Therapeutic communication is no different than how we communicate in general conversation outside of health care." Everyday communication lacks the structured techniques (e.g., active listening, open-ended questions, empathy) used in therapeutic communication.
D. "Therapeutic communication is not as important as medication in the care of our clients." While medications are critical for treatment, communication is equally vital because it affects adherence, trust, and overall well-being.
Correct Answer is B
Explanation
A. Dementia is a progressive cognitive decline that affects memory, reasoning, and behavior. While exhaustion and distraction could be seen in dementia, it is unlikely in an otherwise healthy nurse.
B. Burnout is a state of physical, emotional, and mental exhaustion caused by chronic workplace stress. Symptoms include fatigue, cynicism, reduced effectiveness, and dissatisfaction with work.
C. Traumatic brain injury (TBI) results from a head injury and leads to cognitive and physical symptoms like memory loss, headaches, and coordination issues, which do not align with the scenario.
D. Bipolar disorder involves episodes of mania and depression, not just exhaustion and dissatisfaction. It is a clinical mental health condition, whereas burnout is work-related stress.
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