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
deception.
advocacy.
harm.
paternalism.
The Correct Answer is C
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Negligence is the failure to exercise the care that a reasonably prudent person would exercise in similar circumstances. While administering the wrong medication is a breach of duty, legal charges of negligence might not fully capture the severity of a serious untoward reaction resulting from a medication error by a professional.
Choice B rationale
Malpractice is a specific type of negligence committed by a professional, such as a nurse, in the performance of their professional duties. Administering the wrong medication, leading to a serious adverse reaction, falls under the scope of professional nursing practice and can be considered a breach of the professional standard of care, thus potentially leading to charges of malpractice.
Choice C rationale
Assault is an intentional act that creates a reasonable apprehension of immediate harmful or offensive contact. Administering medication, even the wrong one, is usually not intended to cause apprehension of harm in the way assault is legally defined.
Choice D rationale
Battery is the intentional touching of another person without consent. While administering the wrong medication involves touching without consent, the more appropriate legal charge in a professional healthcare setting where harm results from a breach of duty is typically malpractice. .
Correct Answer is A
Explanation
Choice A rationale
Before delegating any nursing task, the nurse must first determine if the action is permissible under the state's nurse practice act and the employing agency's policies. These regulations define the scope of practice for nurses and the tasks that can be safely and legally delegated to unlicensed personnel. If delegation is not allowed by these governing bodies, the subsequent questions become irrelevant.
Choice B rationale
While it is crucial to ensure that the UAP has been adequately trained and is competent to perform the delegated task safely and correctly, this consideration comes after establishing the legality and permissibility of the delegation according to the nurse practice act and agency policy. Training is important for safe implementation but not the initial determining factor.
Choice C rationale
Appropriate supervision is necessary when delegating tasks to UAPs to ensure client safety and provide guidance. However, the ability to delegate the task itself must first be established by legal and policy guidelines. Supervision is a component of safe delegation but not the primary question determining if delegation is even an option.
Choice D rationale
Evaluating the client's past response to a treatment might inform how the task is performed or any specific observations needed, but it does not determine the fundamental question of whether the task can be delegated to a UAP in the first place. Legal and policy frameworks dictate the scope of delegation, regardless of the client's history. .
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