A client on a psychiatric unit states, “It’s a waste of time being here. I can’t talk to you or anyone.” Which is the correct nursing response?

Choice A reason: The irresistible impulse test focuses on a defendant’s inability to control their actions due to mental illness, even if they understand the act’s wrongfulness. The scenario emphasizes the patient’s lack of understanding of wrongfulness, not impulse control, making this choice incorrect for the legal standard described.

Choice B reason: The substantial capacity test, part of the Model Penal Code, assesses whether a defendant lacks the capacity to appreciate the criminality of their conduct or conform to the law. The scenario specifically highlights not understanding wrongfulness, aligning more directly with M’Naghten, making this less precise.

Choice C reason: The Durham Rule states that a defendant is not criminally responsible if their act was a product of mental disease. It is broader and less specific than M’Naghten, which focuses on understanding wrongfulness, making it less applicable to the scenario described.

Choice D reason: The M’Naghten Rule holds that a defendant is not guilty by reason of insanity if, due to mental illness, they did not understand the nature or wrongfulness of their actions. This directly matches the scenario’s emphasis on the patient’s inability to understand wrongfulness, making it the correct choice.

Choice A reason: Leaving a restrained patient unattended for 2 hours violates safety standards, as restraints pose risks like injury or respiratory compromise. Regular monitoring is required to assess circulation, skin integrity, and psychological distress, ensuring patient safety, making this choice incorrect.

Choice B reason: Restraining all four limbs tightly risks injury, such as nerve damage or impaired circulation, and violates least-restrictive restraint principles. Restraints should allow minimal movement and be applied only as necessary, with regular reassessment, making this choice incorrect.

Choice C reason: A provider’s face-to-face evaluation within 1 hour is required by regulations to ensure restraints are justified and safe. This assesses the patient’s condition, mental status, and need for continued restraint, minimizing harm and ensuring compliance, making this the correct choice.

Choice D reason: Documenting restraint use only at shift’s end is inadequate, as regulations require ongoing documentation of restraint rationale, patient condition, and monitoring. Delayed documentation risks missing critical changes, compromising care and legal compliance, making this choice incorrect.