A mental health nurse is planning care for a group of clients.
Which of the following clients should the nurse identify as having a contraindication for applying restraints?

Choice A rationale:

Intrusive and judgmental: Asking "Why did you wear clean clothes and comb your hair today?" directly challenges the client's behavior and implies that she needs to justify her actions. This can make the client feel defensive and less likely to open up.

Focuses on the past: The directs attention to the client's previous lack of self-care, which can reinforce negative feelings and discourage progress.

Assumes motivation: It presumes that the client made a conscious decision to change her appearance based on a specific reason, which may not be accurate and can invalidate her experience.

Choice B rationale:

Presumptuous and premature: Concluding that "Your mood must be lifting because you have on clean clothes and have combed your hair" makes assumptions about the client's internal state without proper assessment.

Oversimplifies depression: It suggests that improvements in self-care directly equate to mood improvement, which disregards the complexity of depression and its varied manifestations.

Can create pressure: The statement can inadvertently pressure the client to feel or act a certain way to meet the nurse's expectations, hindering genuine progress.

Choice D rationale:

Paternalistic and condescending: Expressing "Oh, I'm so pleased that you finally put on clean clothes" implies that the nurse has been waiting for or expecting this change, placing the nurse in a position of authority and potentially undermining the client's autonomy.

Focuses on the nurse's feelings: The statement centers on the nurse's approval rather than acknowledging the client's efforts and perspective.

Can reinforce dependency: It can foster a dynamic where the client seeks external validation for her actions, rather than developing internal motivation for self-care.

Choice C rationale:

Observational and non-judgmental: The statement "I see that you have on clean clothes and have combed your hair" simply acknowledges the client's actions without imposing any interpretation or judgment.

Invites conversation: It provides an opportunity for the client to elaborate on her choices if she feels comfortable, promoting autonomy and self-expression.

Validates effort: It subtly recognizes the client's efforts without explicitly praising or criticizing, fostering a sense of self- efficacy and encouraging continued self-care.

Demonstrates active listening: It shows that the nurse has been paying attention to the client's progress, which can strengthen the therapeutic relationship and build trust.

Choice A rationale:

It's okay to feel scared. Let's talk about what you are afraid of.

Acknowledges the client's feelings: This response directly acknowledges the client's fear and regret, which is a crucial first step in providing emotional support. It validates the client's experience and creates a safe space for open communication.

Invites the client to share: By inviting the client to talk about their fears, the nurse encourages open expression of emotions. This can help the client to process their feelings and gain a sense of control over their situation.

Promotes understanding: By actively listening to the client's concerns, the nurse can gain a better understanding of their individual needs and fears. This understanding can then guide the nurse in providing tailored support and interventions.

Facilitates coping: Talking about fears can help the client to identify and explore coping strategies. The nurse can assist in this process by offering suggestions, providing resources, and teaching relaxation techniques.

Strengthens the nurse-client relationship: By demonstrating empathy, active listening, and support, the nurse can foster a trusting relationship with the client. This relationship can provide a source of comfort and reassurance during a challenging time.

Choice B rationale:

Don't worry. The important thing is you have now quit smoking.

Dismisses the client's feelings: This response minimizes the client's fear and regret, which can be invalidating and hinder emotional expression.

Focuses on the past: While it's important to acknowledge the positive step of quitting smoking, this response shifts the focus away from the client's current emotional state and concerns about the upcoming surgery.

Offers false reassurance: Telling the client not to worry can be unrealistic and unhelpful, as it doesn't address the underlying fears.

Choice C rationale:

Your doctor is a great surgeon. You will be fine.

Provides premature reassurance: While it's appropriate to express confidence in the medical team, this response may not fully address the client's emotional needs. It can also inadvertently downplay the seriousness of the surgery and potential risks.

Shifts focus away from the client: This response focuses on the surgeon's skills rather than the client's feelings and concerns.

Choice D rationale:

I understand your fears. I was a smoker also.

May be perceived as self-focused: While sharing a personal experience can sometimes build rapport, it's important to ensure the focus remains on the client's needs and experiences. This response could inadvertently shift the attention to the nurse's own story.

Does not directly address the client's fears: While expressing understanding can be helpful, it's important to follow up with s and encouragement to explore the client's specific concerns.