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 D
Explanation
A. Being trustworthy in following through with promises: This describes fidelity, which is the nurse’s duty to keep commitments and maintain trust.
B. Taking actions to promote access to mental health services: This relates to justice, which is about ensuring fairness and equal access to healthcare.
C. Providing ethically sound practice for clients and families: This falls under nonmaleficence and beneficence, ensuring ethical care and minimizing harm.
D. Being truthful and authentic with clients: Veracity means providing truthful and accurate information, ensuring clients receive honest and reliable details about their care.
Correct Answer is B
Explanation
A. Splitting : Splitting is a defense mechanism where a person sees others as all good or all bad, which is not evident in this scenario.
B. Denial: Denial is refusing to accept reality as a way to cope with distress. The client rejects the prognosis and insists on recovery despite medical evidence.
C. Displacement : Displacement is shifting emotions onto a less threatening target (e.g., being angry at a nurse instead of at the bad news).
D. Repression : Repression is unconsciously blocking out distressing thoughts rather than actively rejecting the reality of a loved one’s condition.
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