A nurse is assisting in the care of a 40-year-old female client on an inpatient mental health facility.

Exhibits

For each finding, click to specify if the finding indicates an unrelated condition, improvement of the condition, or worsening of the condition.

Choice A rationale

Reflecting the client's feeling back to them, such as "You are feeling like a failure," acknowledges their emotional state without judgment or dismissal. This therapeutic communication technique validates the client's feelings and encourages further exploration of their thoughts and emotions.

Choice B rationale

While intended to be positive, stating "I see many positive things about you" can minimize the client's current feelings and may not address the underlying reasons for their negative self-perception. It can also sound dismissive of their distress.

Choice C rationale

Saying "You're not the only client who feels this way" can minimize the client's individual experience and may make them feel that their feelings are not unique or important. It does not directly address their specific statement of wanting to be dead.

Choice D rationale

Asking "How can you feel that way when you have so much to live for?" invalidates the client's current feelings and can make them feel misunderstood or defensive. It does not address the depth of their despair and suicidal ideation.

Choice A rationale

Restraint prescriptions for adults typically need to be renewed every 24 hours, according to most healthcare facility policies and regulatory guidelines, not every 48 hours. This frequent review ensures ongoing assessment of the client's need for restraints.

Choice B rationale

Attaching restraints to the side rail of the client's bed is dangerous because the side rail can move independently of the bed frame. This can cause injury to the client if they try to move or reposition themselves, potentially leading to strangulation or other harm. Restraints should be secured to a stable part of the bed frame.

Choice C rationale

Maintaining 2 fingerbreadths between the restraint and the client's skin is the standard to ensure proper circulation and prevent skin breakdown. One fingerbreadth would be too tight and could compromise blood flow and nerve function.

Choice D rationale

Using a quick-release tie is essential for safety when applying restraints. This allows for rapid removal of the restraints in case of an emergency, such as compromised circulation or the need for immediate medical intervention.