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 C

Explanation

Choice A reason: Hourly nursing assessments are important for monitoring safety in restraints but are not the primary legal requirement. Assessments ensure no physical harm, but psychiatric evaluation within one hour is mandated to confirm restraint necessity, making this option secondary in priority for immediate post-restraint protocol.

Choice B reason: Constant supervision may be used, but transitioning to video monitoring after one hour does not meet strict regulatory standards for restraints. Face-to-face psychiatric evaluation within one hour is required to assess ongoing need and ensure patient rights, making this option less accurate for legal compliance.

Choice C reason: Regulatory standards (e.g., CMS, Joint Commission) mandate a face-to-face evaluation by a psychiatrist within one hour of initiating restraints to assess necessity, safety, and alternatives. This ensures compliance with mental health laws, protects patient rights, and prevents overuse, making it the required action.

Choice D reason: Reviewing restraint appropriateness hourly is part of ongoing care but is not the primary requirement. A psychiatrist’s face-to-face evaluation within one hour takes precedence to ensure legal and ethical use, as it confirms the clinical justification for restraints, making this option secondary.

A. I will have to get the client’s signed consent before we can send that information to you B. I will forward your call to the client’s doctor to discuss consent C. I cannot confirm nor deny the existence of any client on this unit D. I am sorry, we are not allowed to give out information about our clients

Correct Answer is A

Explanation

Choice A reason: HIPAA requires client consent to disclose protected health information, like psychological evaluations, to third parties such as employers. This response upholds confidentiality laws, ensuring the client’s privacy is protected while clearly communicating the legal process for information release, making it the most appropriate and compliant action.

Choice B reason: Forwarding the call to the doctor delays the response and does not directly address the confidentiality requirement. While the doctor may handle consent, the nurse can directly inform the employer about the need for signed consent, maintaining clarity and legal compliance in protecting patient privacy.

Choice C reason: Refusing to confirm or deny the client’s presence is overly restrictive and not necessary for an employer’s request. It avoids addressing the consent process, which is the legal requirement for releasing information, making it less direct and potentially confusing in this context.

Choice D reason: Stating that information cannot be given is accurate but incomplete, as it does not explain the consent process. Providing a clear path (obtaining signed consent) ensures compliance with confidentiality laws while addressing the employer’s request, making this response less precise than option a).

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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

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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