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 D
Explanation
Choice A rationale
While understanding the concepts of right and wrong can be important in many aspects of nursing care, it may not be particularly helpful in this context. The patient’s stressors are not necessarily related to moral or ethical dilemmas.
Choice B rationale
The concepts of justified and unjustified might be relevant in some contexts, but they may not provide the necessary context to understand and deliver nursing care for this patient. These
concepts are more related to the evaluation of actions or decisions, rather than understanding a patient’s experience of stress.
Choice C rationale
Good and bad are subjective terms that can vary greatly between individuals. While these concepts might be relevant in some contexts, they may not provide the necessary context to understand and deliver nursing care for this patient.
Choice D rationale
The concepts of adaptive and maladaptive are directly relevant to understanding a patient’s response to stress. Adaptive strategies are those that help an individual cope effectively with stress, while maladaptive strategies are those that do not help, or that may even exacerbate the stress.
Correct Answer is B
Explanation
Choice A rationale
Recommending the client obtain a part-time job may not be the most effective intervention for an adolescent experiencing depression due to a recent move. While employment can provide a sense of purpose and routine, it may also add additional stress and responsibilities that could potentially exacerbate the client’s depression.
Choice B rationale
Scheduling an appointment with a school-based counselor is the most appropriate intervention. School-based counselors are trained to provide emotional support and therapeutic interventions to students dealing with various issues, including depression. They can provide a safe space for the client to express their feelings and can help them develop coping strategies to manage their depression.
Choice C rationale
Arranging a visit with a neurologist is not the most appropriate first intervention. While neurologists can provide treatment for neurological conditions, they are not typically the first point of contact for managing depression.
Choice D rationale
Encouraging the client to engage in more physical activity can be beneficial as exercise has been shown to have a positive effect on mood. However, it may not be sufficient as the sole intervention for an adolescent experiencing depression
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