A nurse is discussing the use of mechanical restraints with a newly licensed nurse. Which of the following situations should the nurse include as an indication for placing a client in mechanical restraints?

Self-destructive behavior despite alternative interventions

Discipline for throwing objects at staff

Punishment for verbally abusing other clients

Coercion to take prescribed medications

Answer and Explanation

The Correct Answer is A

A. Self-destructive behavior despite alternative interventions: Mechanical restraints may be considered when a client poses an immediate risk of harm to themselves, and alternative interventions have been ineffective or are not feasible.

B. Discipline for throwing objects at staff: Mechanical restraints are not appropriate as a form of discipline. Restraints should only be used when there is an imminent risk of harm to the client or others.

C. Punishment for verbally abusing other clients: The use of restraints as a form of punishment is not ethical or appropriate. Restraints should be employed solely to prevent harm, not as a disciplinary measure.

D. Coercion to take prescribed medications: Coercion to take medications is not a valid reason for using mechanical restraints. Alternative approaches, such as therapeutic communication or discussing the need for medications with the client, should be explored.

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Correct Answer is C

Explanation

A. Concrete thinking: Concrete thinking refers to a style of thinking that is focused on immediate and literal aspects of information. The patient's statement involves more than concrete thinking; it includes an irrational belief about the consequences of contagious bacteria, indicating a distorted perception of reality.

B. Agitation: Agitation refers to a state of restlessness or increased activity. The patient's statement does not necessarily reflect agitation but rather a specific paranoid belief about the consequences of bacteria exposure.

C. Paranoia: This is the correct answer. Paranoia involves irrational thoughts and fears of being harmed or persecuted by others. The patient's belief that contagious bacteria are everywhere and will lead to being locked up with other infected people is indicative of paranoid ideation.

D. Poverty of thought: Poverty of thought is characterized by a lack of meaningful or detailed thought content. The patient's statement is not an example of poverty of thought; rather, it involves specific and elaborate content related to a paranoid belief.

A. A Client diagnosed with hypomania who is speaking loudly on the unit B. A client diagnosed with mania who expressed active suicidal ideations C. A client with a history of mania who is pacing in the hallway D. A client diagnosed with hypomania who is complaining of pain

Correct Answer is B

Explanation

Client diagnosed with hypomania who is speaking loudly on the unit: While hypomanic individuals may exhibit increased energy and talkativeness, the urgency is lower compared to a client expressing active suicidal ideations. This client does not pose an immediate threat to themselves or others.

B. Client diagnosed with mania who expressed active suicidal ideations: This is the correct answer. A client with active suicidal ideations is at an elevated risk and requires immediate attention. Suicidal thoughts in the context of mania can be impulsive, and prompt intervention is crucial to ensure the client's safety.

C. Client with a history of mania who is pacing in the hallway: Pacing may be a symptom of mania, but without additional information about the client's current state and any potential immediate risks, the client expressing active suicidal ideations takes precedence.

D. Client diagnosed with hypomania who is complaining of pain: Pain complaints, in the absence of other urgent factors, do not take precedence over active suicidal ideations. The risk of harm to oneself or others is a higher priority.

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A nurse is discussing the use of mechanical restraints with a newly licensed nurse. Which of the following situations should the nurse include as an indication for placing a client in mechanical restraints?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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