A nurse on a mental health unit is discussing restraints and seclusion with a group of newly hired nurses. At which of the following times should a nurse discuss the restraint and seclusion policy with a client?
When a client becomes agitated.
While administering chemical or physical restraints.
During debriefing after restraint removal.
Upon admission.
The Correct Answer is D
Choice A rationale
While it’s important to discuss the restraint and seclusion policy when a client becomes agitated, it’s not the ideal time. The client may not be in a state to fully understand the information due to their heightened emotional state.
Choice B rationale
Discussing the policy while administering chemical or physical restraints is not appropriate. The client may be distressed or resistant, making it difficult for them to comprehend the information.
Choice C rationale
Although debriefing after restraint removal is a crucial part of the process, it’s not the best time to first introduce the restraint and seclusion policy. The client may be physically and emotionally exhausted after the experience.
Choice D rationale
The restraint and seclusion policy should be discussed with the client upon admission. This ensures that the client is aware of the policy ahead of time, which can help reduce anxiety and fear if restraints or seclusion become necessary.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Using EPA registered insect repellants is a form of primary prevention, as it aims to prevent tick bites, which are the primary mode of transmission for Lyme disease.
Choice B rationale
Checking your clothing and body for ticks after being outdoors is a form of secondary prevention. If a tick is found and removed before it has had a chance to transmit the bacteria that cause Lyme disease, this can prevent the disease from occurring.
Choice C rationale
Wearing long-sleeved shirts and pants while outdoors is another form of primary prevention, as it can help prevent tick bites.
Choice D rationale
Notifying your health care provider if you notice a rash (especially a bull’s-eye rash, which is a common early symptom of Lyme disease) is a form of tertiary prevention, as it involves managing the symptoms of an existing disease.
Correct Answer is D
Explanation
Choice A rationale
While a family history of anxiety disorders can increase the risk of developing such disorders, positive childhood experiences can serve as protective factors, reducing the likelihood of developing an anxiety disorder.
Choice B rationale
Although a family history of cancer can cause stress and anxiety, especially if the client is recently unemployed and potentially struggling with financial instability, this does not necessarily mean they are most likely to develop an anxiety disorder. Unemployment can indeed be a source of stress, but it is not a direct cause of anxiety disorders.
Choice C rationale
Not graduating from high school or not completing the GED test can lead to lower socioeconomic status and fewer job opportunities, which can be stressful. However, these factors alone do not make someone most likely to develop an anxiety disorder.
Choice D rationale
A client who had multiple adverse childhood experiences and whose parents both have a history of anxiety disorders is most likely to develop an anxiety disorder. Adverse childhood experiences, such as abuse and neglect, are significant risk factors for the development of anxiety disorders later in life. Furthermore, having parents with a history of anxiety disorders suggests a possible genetic predisposition.
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