A nurse is talking with a patient, and 5 minutes remain in the session. The patient has been silent for most of the session. Another patient comes to the door of the room, interrupts, and says, “I really need to talk to you right now.” The nurse should:

Say to the interrupting patient, “I am not available to talk with you at the present time”

End the unproductive session with the current patient and spend time with the patient who has just interrupted

Invite the interrupting patient to join in the session with the current patient

Tell the patient who interrupted, “This session will be 5 more minutes; then, I will talk with you”

Answer and Explanation

The Correct Answer is D

Choice A reason: Bluntly stating unavailability dismisses the interrupting patient’s needs without offering a solution, potentially escalating distress. This approach lacks therapeutic communication, as it fails to acknowledge the patient’s urgency or provide a clear plan, which is critical in maintaining trust in a mental health setting.

Choice B reason: Ending the current session prematurely disrespects the silent patient’s therapeutic process. Silence may reflect processing or discomfort, requiring time to build trust. Abruptly shifting focus undermines the current patient’s care, potentially worsening their mental health and disrupting the therapeutic relationship.

Choice C reason: Inviting the interrupting patient to join violates confidentiality and disrupts the current patient’s safe space. Combining sessions without consent breaches ethical principles, potentially causing discomfort or mistrust, which hinders therapeutic progress for both patients in a mental health context.

Choice D reason: Acknowledging the interruption and scheduling a follow-up in 5 minutes respects both patients’ needs. It maintains the current patient’s therapeutic time while addressing the interrupting patient’s urgency, ensuring fairness and trust. This approach upholds ethical care and supports a therapeutic environment for mental health treatment.

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Correct Answer is C

Explanation

Choice A reason: Allowing a client with suicidal comments to leave against medical advice is unsafe, as it risks self-harm without immediate intervention. Providing resources does not address acute suicide risk, which requires inpatient stabilization to ensure safety, making this action inappropriate in the context of expressed suicidal ideation.

Choice B reason: Contacting family to persuade the client to stay does not address immediate suicide risk. While family support may be helpful, it lacks legal authority to prevent discharge and does not ensure safety, making it less effective than initiating a commitment for a client with suicidal intent.

Choice C reason: A 302 involuntary commitment is appropriate for a client expressing suicidal ideation, indicating imminent danger to self. This legal action ensures safety through inpatient evaluation and treatment, preventing self-harm. Mental health laws prioritize protection in such cases, making this the most appropriate nursing action.

Choice D reason: Calling security to detain the client is coercive and lacks legal basis without a formal commitment process. It may escalate agitation and violate autonomy. A 302 commitment is the proper legal mechanism to ensure safety for a suicidal client, making detention by security inappropriate.

A. A documented nursing assessment every hour B. Constant one-on-one supervision during the first hour and then video monitoring C. A face-to-face evaluation by the psychiatrist within one hour of restraint D. Review of the appropriateness of restraints every hour

Correct Answer is C

Explanation

Choice A reason: Hourly nursing assessments are important for monitoring safety in restraints but are not the primary legal requirement. Assessments ensure no physical harm, but psychiatric evaluation within one hour is mandated to confirm restraint necessity, making this option secondary in priority for immediate post-restraint protocol.

Choice B reason: Constant supervision may be used, but transitioning to video monitoring after one hour does not meet strict regulatory standards for restraints. Face-to-face psychiatric evaluation within one hour is required to assess ongoing need and ensure patient rights, making this option less accurate for legal compliance.

Choice C reason: Regulatory standards (e.g., CMS, Joint Commission) mandate a face-to-face evaluation by a psychiatrist within one hour of initiating restraints to assess necessity, safety, and alternatives. This ensures compliance with mental health laws, protects patient rights, and prevents overuse, making it the required action.

Choice D reason: Reviewing restraint appropriateness hourly is part of ongoing care but is not the primary requirement. A psychiatrist’s face-to-face evaluation within one hour takes precedence to ensure legal and ethical use, as it confirms the clinical justification for restraints, making this option secondary.

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A nurse is talking with a patient, and 5 minutes remain in the session. The patient has been silent for most of the session. Another patient comes to the door of the room, interrupts, and says, “I really need to talk to you right now.” The nurse should:

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Correct Answer is C

Explanation

An adult client was put in restraints after all other attempts to reduce aggression have failed. Which is required now that restraints have been instituted by the nurse?

Correct Answer is C

Explanation

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