A male client age 56 years is experiencing withdrawal from alcohol and is placing himself at risk for falls by repeatedly attempting to scale his bedrails.
Benzodiazepines have failed to alleviate his agitation, and the nurse is considering obtaining an order for physical restraints to ensure his safety.
The nurse should recognize that this measure may ethically constitute

Choice A rationale

Deception involves intentionally misleading someone. Applying physical restraints for the client's safety, while ethically complex, is a transparent intervention intended to prevent harm, not to deceive the client. The intent is protective, even if the client resists.

Choice B rationale

Advocacy involves supporting the client's best interests and rights. While the nurse's concern for the client's safety is a form of advocacy, the act of physical restraint itself can be seen as limiting the client's autonomy, potentially conflicting with a purely advocacy-based approach.

Choice C rationale

Harm, in an ethical context, refers to physical or psychological injury or damage. While the intention of restraints is to prevent falls and physical harm, the application of restraints can itself cause physical injury (e.g., skin breakdown, nerve damage) or psychological distress (e.g., fear, humiliation, loss of control). Therefore, it is a measure that carries the potential for harm.

Choice D rationale

Paternalism involves making decisions for a client that the healthcare professional believes are in the client's best interest, even against the client's wishes. Applying restraints to prevent the client from harming themselves, despite their resistance, aligns with the concept of paternalism, prioritizing safety over autonomy in this specific situation.

Choice A rationale

Asking "How loud is his snoring?" is subjective and difficult for the spouse to quantify accurately. While loudness can be a factor, it doesn't directly address potential underlying medical conditions like obstructive sleep apnea.

Choice B rationale

Determining the frequency of awakenings due to snoring provides some information about the impact on the spouse's sleep but doesn't offer specific details about the nature of the snoring itself or potential pauses in breathing.

Choice C rationale

Asking "Is there silence after snoring which then is followed with a snort?" directly inquires about a pattern indicative of obstructive sleep apnea. Apneic episodes involve cessation of breathing (silence), followed by a gasp or snort as the airway reopens.

Choice D rationale

Knowing the duration of snoring each night provides a general overview but doesn't offer specific details about the characteristics of the snoring, such as pauses in breathing or gasping, which are crucial for identifying potential sleep disorders. .