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

Crisis care

Case management

Coordination of care

Care in the least restrictive environment

Answer and Explanation

The Correct Answer is D

Choice A reason:
Crisis care is an important component of the mental health care continuum, providing immediate support during acute episodes. However, it is not the primary goal of the continuum of care. The goal is to provide ongoing, comprehensive support that promotes stability and recovery.

Choice B reason:
Case management is a crucial aspect of mental health care, ensuring that clients receive coordinated and continuous services. While it plays a significant role in the continuum of care, it is not the overarching primary goal.

Choice C reason:
Coordination of care is essential for effective mental health treatment, involving the integration of various services and providers. However, it is a means to an end rather than the primary goal itself.

Choice D reason:
Care in the least restrictive environment is the primary goal of the mental health care continuum. This principle emphasizes providing care in settings that allow the greatest level of independence and normalcy for the client while ensuring their safety and well-being. It aims to avoid unnecessary institutionalization and promote community-based care.

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Correct Answer is B

Explanation

Choice A reason:
Explaining unit rules and policies regarding unacceptable behaviors is important for maintaining order and safety within the facility. However, this action is more about setting boundaries and expectations rather than supporting the client’s autonomy. Autonomy involves respecting the client’s right to make their own decisions, which is not directly addressed by merely explaining rules.
Choice B reason:
Supporting the client’s wish to refuse prescribed medications demonstrates respect for the client’s autonomy. Autonomy is the ethical principle that recognizes the right of individuals to make informed decisions about their own care. By supporting the client’s decision to refuse medication, the nurse acknowledges and respects the client’s right to make choices about their treatment, even if those choices differ from medical advice.
Choice C reason:
Making sure the client understands expectations for client participation is essential for clear communication and effective treatment planning. However, this action is more about ensuring compliance and understanding rather than promoting autonomy. While it is important for clients to understand what is expected of them, this does not necessarily empower them to make their own decisions.
Choice D reason:
Encouraging client feedback about satisfaction with the facility experience is a valuable practice for improving care and ensuring that clients feel heard. However, this action focuses on gathering feedback rather than directly supporting the client’s autonomy. While it contributes to a client-centered approach, it does not specifically address the client’s right to make independent decisions about their care.

A. Anticipate removing the restraints every 4 hours. B. Secure the restraints to the lowest bar of the side rail. C. Secure the restraints using a quick-release tie. D. Ensure four fingers fit under the restraints to prevent constriction.

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.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a mental illness. Which of the following actions by the nurse demonstrates the ethical concept of autonomy?

Correct Answer is B

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 nurse is talking with a client who has schizophrenia. Suddenly the client states, “I’m frightened. Do you hear that? The voices are telling me to do terrible things.” Which of the following responses by the nurse is appropriate?

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?

After being scolded by his supervisor at work, a man comes home and punches several holes in his walls and yells at his significant other. Which of the following defense mechanisms does this scenario depict?

When communicating with a client, which would a nurse use to convey positive body language?

A nurse is developing a plan of care integrating Maslow’s hierarchy of needs. Which area would the nurse identify as the priority?

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 medical record of a client who has a new prescription for chlorpromazine for the treatment of schizophrenia. Which of the following findings indicates a contraindication to chlorpromazine?