Which intervention by a psychiatric nurse implements the ethical principle of autonomy?
Intervening when a client with a history of self-mutilation attempts to self-injure.
Suggesting that two clients who were fighting be restricted to the unit.
Staying with a client who is demonstrating a high level of anxiety.
Exploring alternative solutions with a client, who later chooses one alternative.
The Correct Answer is D
Choice A Reason
Intervening when a client attempts self-injury may be necessary to ensure the client's immediate safety. However, this action does not primarily implement the ethical principle of autonomy. Autonomy involves respecting the client's right to make their own decisions, including the right to refuse treatment. In cases of self-harm, the nurse must balance the ethical principles of autonomy and nonmaleficence (the duty to do no harm)
Choice B Reason
Suggesting restrictions for clients who were fighting might be a measure to maintain safety within the unit. However, this suggestion does not uphold the principle of autonomy, as it involves limiting the clients' freedom and choices. The ethical principle of autonomy emphasizes the clients' right to make independent choices and to control their own actions.
Choice C Reason
Staying with a client who is experiencing a high level of anxiety is a supportive action that can be therapeutic. While it demonstrates care and may provide comfort, it does not directly implement the principle of autonomy. Autonomy is about the capacity to make informed and voluntary decisions, and while support is important, it does not equate to enabling decision-making.
Choice D Reason
Exploring alternative solutions with a client and allowing them to choose an option embodies the ethical principle of autonomy. This approach respects the client's right to be involved in their own care and to make decisions based on their values and beliefs. It empowers the client to have control over their treatment and respects their capacity for self-determination.
In psychiatric nursing, respecting autonomy means acknowledging the client's right to make choices about their care and treatment. It involves providing all necessary information and supporting the client in making informed decisions. By exploring options and allowing the client to choose, the nurse facilitates autonomy and supports the client's right to direct their own care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D","E"]
Explanation
Choice a reason:
Assessing capillary refill and the color of the extremity is essential for determining the vascular status of the limb. A normal capillary refill time is less than 2 seconds and indicates good blood flow. The color should be consistent with the rest of the body, without pallor or cyanosis, which could indicate compromised circulation.
Choice b reason:
Checking pedal pulses is another critical aspect of assessing vascular integrity. The presence of strong and equal pulses in both feet suggests that the blood supply to the lower extremities is not compromised.
Choice c reason:
While the ACE wrap and Velcro boot are part of the postoperative management to provide support and protection to the affected limb, and hanging weights might be used for traction, these are not part of the physiological assessment of the extremity.
Choice d reason:
Monitoring pin sites for signs of infection, such as redness, swelling, or discharge, is crucial in a client with ORIF. Infection can lead to complications that may affect the healing process and the integrity of the fixation.
Choice e reason:
Evaluating the temperature, sensation, and movement of toes helps in assessing for potential nerve damage or compartment syndrome. Any changes in these parameters should be reported immediately as they may signify serious complications.
Correct Answer is D
Explanation
Choice A reason:
While polyhydramnios can be associated with congenital anomalies or fetal distress, it is not a direct indication of these conditions. Polyhydramnios refers specifically to the excessive accumulation of amniotic fluid. Congenital anomalies may lead to polyhydramnios if they affect the fetus's ability to swallow and process amniotic fluid normally, but the presence of polyhydramnios alone does not confirm these conditions.
Choice B reason:
Elevated levels of alpha-fetoprotein (AFP) in the amniotic fluid can be indicative of neural tube defects or other fetal abnormalities, but they are not a defining characteristic of polyhydramnios. Normal AFP levels in amniotic fluid at 15 to 21 weeks' gestation range from 10 to 150 ng/ml. Polyhydramnios is diagnosed based on the volume of amniotic fluid, not the AFP levels.
Choice C reason:
Carrying more than one fetus can lead to an increased amount of amniotic fluid, potentially resulting in polyhydramnios. However, the diagnosis of polyhydramnios itself does not imply a multiple gestation pregnancy. It simply indicates that there is more amniotic fluid than usual.
Choice D reason:
Polyhydramnios is defined as an excessive amount of amniotic fluid. It is typically diagnosed when the amniotic fluid index (AFI) exceeds 24 cm or the single deepest pocket (SDP) measures more than 8 cm. This condition can occur due to various reasons, including fetal anomalies, maternal diabetes, and other medical conditions.

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