The client feels that the client’s rights have been violated. Placing a client in restraints before using other methods of intervention violates which of the client’s rights?

Right to do no harm by the nurse

Right to provide informed consent

Right to receive confidential and respectful care

Right to receive the least restrictive treatment

Answer and Explanation

The Correct Answer is D

Choice A reason: The right to do no harm (nonmaleficence) is an ethical principle, not a specific client right. While premature restraints may cause harm, this option does not directly address the legal right violated, which is the use of least restrictive interventions, making it less precise.

Choice B reason: Informed consent involves agreeing to treatments, not the use of restraints, which is a safety intervention. While clients should be informed, premature restraint use violates the right to least restrictive care, not consent, as restraints are not typically consensual interventions.

Choice C reason: Confidential and respectful care relates to privacy and dignity, not the method of intervention. Premature restraints violate the principle of using less invasive options first, not confidentiality or respect, making this right irrelevant to the specific violation described in the scenario.

Choice D reason: The right to least restrictive treatment requires using non-invasive interventions (e.g., de-escalation) before restraints. Premature restraint use violates this right, as mental health laws mandate the least coercive measures to ensure safety, prioritizing patient autonomy and minimizing harm, making this the correct answer.

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Correct Answer is D

Explanation

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.

A. The client reports left-sided flank pain B. Blood pressure 138/86 mm Hg and heart rate 92 bpm C. The urine is cloudy and has visible sediment with a foul odor D. Urine output of 150 mL over the past 8 hours

Correct Answer is D

Explanation

Choice A reason: Left-sided flank pain may suggest kidney stones or infection but is not specific to AKI. Pain can occur in various conditions, including pyelonephritis or ureteral obstruction, and does not directly indicate reduced glomerular filtration or oliguria, which are hallmarks of AKI, making it less urgent.

Choice B reason: Blood pressure of 138/86 mm Hg and heart rate of 92 bpm are within normal ranges and not specific to AKI. While hypertension can occur in AKI due to fluid overload, these values do not strongly suggest AKI without other signs like oliguria or lab abnormalities.

Choice C reason: Cloudy urine with sediment and foul odor suggests a urinary tract infection, not necessarily AKI. Infections can coexist with AKI but are not diagnostic. AKI is characterized by reduced urine output and elevated creatinine, not primarily by urine appearance, making this finding less indicative.

Choice D reason: Urine output of 150 mL in 8 hours (450 mL/day) indicates oliguria, a key sign of AKI, where kidneys fail to filter adequately, reducing urine production. This can lead to fluid overload and toxin accumulation, necessitating urgent provider notification to evaluate and manage potential AKI complications like hyperkalemia.

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The client feels that the client’s rights have been violated. Placing a client in restraints before using other methods of intervention violates which of the client’s rights?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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:

Correct Answer is D

Explanation

The nurse is caring for an acutely ill client. Which assessment finding should prompt the nurse to inform the healthcare provider that the client may be exhibiting signs of acute kidney injury (AKI)?

Correct Answer is D

Explanation

A nurse assesses a confused older adult. The nurse experiences sadness and reflects, “The patient is like one of my grandparents… so helpless.” What feelings does the nurse describe?

The client feels that the client’s rights have been violated. Placing a client in restraints before using other methods of intervention violates which of the client’s rights?

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?

A nurse is reviewing an electronic medical record to determine if a client’s rights have been violated by another member of the healthcare team. Which finding will the nurse identify that would indicate a violation of the client’s rights?

A client with end-stage kidney disease is scheduled to begin hemodialysis. The nurse is working with the client to adapt the client’s diet to maximize the therapeutic effect and minimize the risks of complications. The client’s diet should include which of the following modifications?

The nurse is sitting down with a client to begin a conversation. Which position will the nurse take to convey acceptance of the client?