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?
A client who has Obsessive Compulsive Disorder (OCD) and insists on mopping the floor in the day room.
A client who has a personality disorder and tries to manipulate the staff to gain privileges.
A client who has Bulimia Nervosa and refuses to come to the dining room for meals.
A client who is just recovering from a benzodiazepine overdose.
The Correct Answer is D
Choice A rationale: A client with Obsessive Compulsive Disorder (OCD) who insists on mopping the floor in the day room does not pose a direct threat to themselves or others. OCD is characterized by obsessions (persistent, intrusive
thoughts) and compulsions (repetitive behaviors that the person feels compelled to perform). The act of mopping the floor could be a compulsion for this client. While it may be disruptive or unusual, it is not harmful. Therefore, restraints would not be appropriate in this situation.
Choice B rationale: A client with a personality disorder who tries to manipulate staff to gain privileges can be challenging to manage, but this behavior does not warrant the use of restraints. Personality disorders are characterized by enduring patterns of behavior, cognition, and inner experience that deviate from the expectations of the individual’s culture. These patterns are inflexible and pervasive across many personal and social situations.
While manipulation can be frustrating for staff, it is not a danger to the client or others, and other interventions should be used to manage this behavior.
Choice C rationale: A client with Bulimia Nervosa who refuses to come to the dining room for meals is exhibiting behavior related to their eating disorder, but this does not justify the use of restraints. Bulimia Nervosa is characterized by recurrent episodes of binge eating followed by compensatory behaviors such as vomiting, fasting, or excessive exercise. Refusal to eat in a communal setting like a dining room is not uncommon for individuals with eating disorders. This behavior should be addressed through therapeutic interventions, not restraints.
Choice D rationale: A client who is just recovering from a benzodiazepine overdose is the correct answer. Restraints are contraindicated for this client because they could cause physical harm. After a benzodiazepine overdose, the client may experience symptoms such as drowsiness, confusion, and impaired coordination. Restraints could increase the risk of injury, particularly if the client becomes agitated or tries to remove them. In addition, restraints could potentially interfere with medical treatment for the overdose.
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Related Questions
Correct Answer is D
Explanation
Choice A rationale: Fear of rejection from staff is not typically a driving factor for the repetitive behaviors seen in OCD. While social anxiety can be a component of many mental health disorders, the compulsions in OCD are usually driven by intrusive thoughts or fears that are specific to the individual, rather than fears about social rejection.
Choice B rationale: Narcissistic Personality Disorder (NPD) is a separate condition from OCD. While individuals with NPD may exhibit certain repetitive behaviors, these are typically driven by a need for admiration and a lack of empathy for others, rather than the intrusive thoughts and fears that drive the compulsions in OCD12.
Choice C rationale: While certain medications can have side effects that might cause unusual behaviors, the repetitive behaviors (compulsions) seen in OCD are not typically a side effect of antidepressant medications. In fact, certain types of antidepressants are often used in the treatment of OCD12.
Choice D rationale: The repetitive behaviors observed in individuals with OCD, such as repeatedly applying, removing, and reapplying makeup, are indeed attempts to reduce anxiety. These individuals experience intrusive thoughts, fears, or images (obsessions) that cause significant anxiety. The repetitive behaviors (compulsions) are performed in an attempt to alleviate the distress caused by these obsessions. Despite the temporary relief, the individual often ends up trapped in a cycle of obsessions and compulsions.
Correct Answer is B
Explanation
While the client's statement might seem like other defense mechanisms, here's why Denial is the most fitting choice: Denial:
Involves refusing to acknowledge a painful or threatening reality.
The client attributes their cough, a potential symptom of lung cancer, to a common cold, dismissing the possibility of their condition worsening.
This allows them to avoid the emotional distress associated with facing their illness. Other options and their rationales:
Reaction formation (Choice A): This involves expressing the opposite of what one truly feels or desires. The client doesn't show any outward signs of expressing emotions opposite to their actual feelings about their health.
Suppression (Choice C): This involves consciously pushing unpleasant thoughts or feelings out of awareness. While the client might downplay the cough, they haven't completely pushed the thought of their illness away.
Regression (Choice D): This involves reverting to an earlier stage of development in response to stress. There's no indication of the client displaying behaviors characteristic of an earlier developmental stage.
Addressing other potential mechanisms:
Displacement: Redirecting emotions towards a less threatening target is not evident in the scenario.
Rationalization: Justifying behavior in a way that avoids facing the true reasons is not seen in the client's explanation. Projection: Attributing one's own feelings or desires to others is not present in the client's statement.
Remember:
Denial is a common coping mechanism for dealing with difficult realities like illness.
It's crucial for the nurse to assess the extent of the client's denial and offer support without judgment.
The goal is to help the client acknowledge their illness while providing emotional support and resources for managing their condition.
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