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

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.

Choice A rationale

Being married is generally considered a protective factor against depression due to increased social support and companionship. Research often indicates that individuals in stable marital relationships tend to have lower rates of depression compared to unmarried individuals.

Choice B rationale

Chronic illness is a significant risk factor for depression. The ongoing physical discomfort, limitations in daily activities, and psychological burden associated with chronic conditions can increase vulnerability to mood disorders. The physiological and emotional impact of managing a long-term illness contributes to this increased risk.

Choice C rationale

Alcohol use disorder is strongly associated with an increased risk of depression. Alcohol is a central nervous system depressant that can disrupt neurotransmitter balance in the brain, leading to or exacerbating depressive symptoms. Furthermore, the social and personal consequences of alcohol abuse can contribute to feelings of isolation and despair.

Choice D rationale

Early childhood trauma is a well-established risk factor for developing depression later in life. Adverse experiences during childhood can have long-lasting effects on brain development, stress response systems, and emotional regulation, increasing susceptibility to mental health disorders, including depression.

Choice E rationale

Middle-class economic status is not typically identified as a specific risk factor for depression. While socioeconomic factors can influence mental health, depression can affect individuals across all economic strata. Poverty and financial instability are more commonly associated with increased risk.