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
While it’s important for a child to be taken to the hospital if they develop difficulty breathing, this is more of a tertiary prevention strategy, as it involves managing the symptoms of an existing disease.
Choice B rationale
Testing the child to determine the cause of their illness is a form of secondary prevention. By identifying whether the child has SARS-CoV-2, appropriate measures can be taken to treat the illness and prevent further spread.
Choice C rationale
Immunization is a form of primary prevention, as it aims to prevent the disease from occurring in the first place.
Choice D rationale
Wearing a mask can help prevent the spread of SARS-CoV-2, but it is more of a primary prevention strategy, as it aims to prevent exposure to the virus.
Correct Answer is C
Explanation
Choice A rationale
While voice tremors can be a symptom of anxiety, they are not specifically associated with panic level anxiety. Voice tremors could be due to a variety of factors, including nervousness, fear, or certain medical conditions.
Choice B rationale
Shakiness can be a symptom of anxiety, but it is not specific to panic level anxiety. It could be a physical response to fear, stress, or even low blood sugar.
Choice C rationale
Depersonalization, a feeling of being detached or disconnected from oneself, is a common symptom of panic level anxiety. Individuals may feel as if they are observing themselves from an outside perspective.
Choice D rationale
Poor concentration can be a symptom of many mental health conditions, including anxiety. However, it is not specific to panic level anxiety and can be influenced by a variety of factors, such as stress, lack of sleep, or certain medications.
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