On review of the client’s record, the nurse notes that the admission was voluntary. Based on this information, the nurse plans care anticipating which client behavior?

Anger and aggressiveness directed toward others

Fearfulness regarding treatment measures

Willingness to participate in the planning of the care and treatment plan

An understanding of the pathology and symptoms of the diagnosis

Answer and Explanation

The Correct Answer is C

Choice A reason:
Anger and aggressiveness directed toward others are not typically associated with voluntary admission. Clients who voluntarily seek treatment are usually motivated to improve their condition and are less likely to exhibit aggressive behaviors towards others. Aggressiveness may be more common in involuntary admissions where the client feels coerced.

Choice B reason:
Fearfulness regarding treatment measures can occur in any client, regardless of whether the admission is voluntary or involuntary. However, clients who voluntarily admit themselves are generally more open to treatment and less likely to exhibit significant fearfulness about the treatment process.

Choice C reason:
Willingness to participate in the planning of the care and treatment plan is a common behavior in clients who have voluntarily admitted themselves. These clients are typically motivated to engage in their treatment and collaborate with healthcare providers to achieve their health goals. Voluntary admission often indicates a proactive approach to managing their condition.

Choice D reason:
An understanding of the pathology and symptoms of the diagnosis is not necessarily linked to the nature of the admission. While some clients may have a good understanding of their condition, others may not, regardless of whether their admission was voluntary or involuntary. Education about the diagnosis is an important part of the treatment process for all clients.

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Correct Answer is C

Explanation

Choice A reason:

Anticipating removing the restraints every 4 hours is not the best practice. Restraints should be checked frequently, typically every 2 hours, to assess the client’s circulation, skin integrity, and need for continued restraint. The goal is to use restraints for the shortest duration possible.

Choice B reason:

Securing the restraints to the lowest bar of the side rail is incorrect. Restraints should be secured to a part of the bed frame that moves with the client, not to the side rail, to prevent injury and ensure the client’s safety.

Choice C reason:

Securing the restraints using a quick-release tie is the correct action. This ensures that the restraints can be quickly and easily removed in case of an emergency, prioritizing the client’s safety.

Choice D reason:

Ensuring four fingers fit under the restraints to prevent constriction is not accurate. The correct practice is to ensure that two fingers can fit between the restraint and the client’s skin to prevent constriction and ensure proper circulation.

Correct Answer is C

Explanation

Choice A reason:

Choice B reason:

Choice C reason:

Choice D reason:

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On review of the client’s record, the nurse notes that the admission was voluntary. Based on this information, the nurse plans care anticipating which client behavior?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A newly licensed nurse is applying prescribed wrist restraints on a client. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A newly licensed nurse is applying prescribed wrist restraints on a client. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A psychiatric-mental health nurse is working on an inpatient unit that uses a privilege system. The nurse understands that this intervention integrates which group of theories?

When engaged in therapeutic communication with a client who has been diagnosed with a mental disorder, which is the most important principle for a nurse to keep in mind?

A nurse is reviewing the DSM-5 diagnostic criteria for schizophrenia. Which of the following symptoms must be present for a client to be diagnosed with schizophrenia? (Select all that apply.)

When describing the continuum of care for mental health, which would the nurse identify as the primary goal?

A client receives a court order for commitment. Which concept exemplifies a “least restrictive environment”?

A woman comes into the Emergency Department in a severe state of anxiety following a car accident. The appropriate nursing intervention is to:

The nurse calls security and has physical restraints applied to a client who was admitted voluntarily when the client becomes verbally abusive, demanding to be discharged from the hospital. Which represents the possible legal ramifications for the nurse associated with these interventions?