A nurse is assisting in the care of a client who is in restraints following an episode of violence. Which of the following information should the nurse document in the client's medical record? (Select all that apply.)

Providing opportunities for nutrition and toileting

Observing range of motion of client's extremities

Observation of the client once per hour

Attempts at less restrictive interventions

Names of staff members caring for the client

Answer and Explanation

Correct Answer : A,B,D,E

A.   It is essential to document the times when the client was offered opportunities for nutrition and toileting while in restraints. This includes offering food and fluids at regular intervals and assisting the client with toileting needs as required. Documentation ensures that these basic needs are met despite the restraint status.
B.   Documenting observations of the client's range of motion helps monitor for any signs of discomfort, circulation issues, or injury related to being in restraints. This documentation is crucial for ensuring the client's safety and well-being during restraint use.
C.   observation of the client should be conducted more frequently than once per hour, especially after an episode of violence, to closely monitor the client's condition and response to the restraints.
D.   Documenting attempts at less restrictive interventions shows that the healthcare team is actively working to minimize the use of restraints whenever possible. This might include attempts to de-escalate the client, use of medications, or other interventions aimed at reducing agitation or violence without resorting to physical restraints.
E.   It is important to document the names of staff members who are directly involved in the care of a restrained client. This ensures accountability and provides a clear record of who has been caring for the client during their restraint period.

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Correct Answer is D

Explanation

A. This scenario involves the issue of informed consent and medical ethics rather than libel. It pertains to the client's right to make decisions about their treatment. While administering medication without consent could have legal and ethical implications, it does not relate to libel.
B. This is an example of negligence or breach of duty, which could result in harm to the client. It pertains to safety protocols and standards of care rather than libel. Properly securing a client in a wheelchair is crucial for their safety and is not related to libel.
C. This example involves ethical considerations around coercion and restraint use. Threatening to apply restraints without a legitimate reason or following proper protocols could be considered a violation of

the client's rights. However, it does not constitute libel, as it does not involve false statements that harm someone's reputation through written or broadcasted communication.
D. This is an example of libel. Documenting false information about a client's substance use history can damage their reputation and potentially lead to negative consequences for the client, such as improper treatment or legal ramifications. Accurate and truthful documentation is essential in healthcare to ensure proper care and respect for the client's rights.

A. "You must be mistaken. Snakes cannot be in the clinic." B. "Your provider requires this blood specimen." C. "I'm using a syringe to obtain your blood, not a snake." D. "I don't see a snake, but that must be scary for you."

Correct Answer is D

Explanation

A. This response dismisses the client's experience and hallucination as a mistake. It invalidates the client's feelings and does not acknowledge the client's reality. It can increase the client's distress and undermine trust in the nurse's communication.
B. While this statement provides factual information about the need for the blood specimen, it does not address the client's hallucination or their fear related to it. It may come off as indifferent to the client's feelings and concerns.
C. This option dismisses the client’s feelings without addressing them appropriately.
D. This response validates the client's experience and expresses empathy for their feelings of fear. It acknowledges the hallucination without confirming its reality and shows understanding of how

frightening the experience might be for the client. This response is supportive and helps build trust between the nurse and the client.

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A nurse is assisting in the care of a client who is in restraints following an episode of violence. Which of the following information should the nurse document in the client's medical record? (Select all that apply.)

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Naxlex Comprehensive Predictor Exams

A nurse on a mental health unit is assisting with developing an in-service for staff members about legal issues. Which of the following examples should the nurse include as an example of libel?

Correct Answer is D

Explanation

A nurse in a mental health facility is collecting a blood specimen from a client. The client is hallucinating and states, "That looks like a snake, and I won't let it take all of my blood." Which of the following responses should the nurse make?

Correct Answer is D

Explanation

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