A nurse is reviewing treatment alternatives for managing a client's behavior. The nurse should identify that which of the following examples describes the least restrictive alternative?
An adult client is confined with physical restraints after throwing chairs at other clients and staff.
An adolescent is taken to a secure, quiet room after threatening and lashing-out at other clients and staff.
An 8-year-old child is asked to return to their room after yelling at other children during a group therapy session.
An adult client is given clozapine, an antipsychotic medication, after punching a wall with their fist and telling everyone that they intend to hurt them.
The Correct Answer is C
A. An adult client is confined with physical restraints after throwing chairs at other clients and staff. Physical restraints are highly restrictive and should be used as a last resort when safety is at risk.
B. An adolescent is taken to a secure, quiet room after threatening and lashing out at other clients and staff. Seclusion is restrictive but less so than physical restraints; however, other interventions should be attempted first.
C. An 8-year-old child is asked to return to their room after yelling at other children during a group therapy session. This is the least restrictive intervention, as it involves verbal redirection rather than confinement or medication.
D. An adult client is given clozapine, an antipsychotic medication, after punching a wall with their fist and telling everyone that they intend to hurt them. Medication can be restrictive when used for behavior control rather than for medical necessity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "Implied consent cannot be assumed if a client is unable to communicate their wishes in an emergency situation." In emergencies, implied consent is assumed if immediate treatment is necessary to prevent harm.
B. "A nurse can explain the benefits and risks of treatment to a client to obtain informed consent." Only the provider (physician, NP, or PA) can obtain informed consent; the nurse can reinforce and clarify information but not obtain it.
C. "Informed consent must include information about potential alternative treatments that are available to the client." Informed consent requires the provider to discuss potential alternative treatments, risks, benefits, and consequences of refusal.
D. "Implied consent cannot be assumed until a client verbalizes their desire to receive treatment." Implied consent can be assumed based on actions, such as extending an arm for a blood draw.
Correct Answer is A
Explanation
A. Beneficence is the duty to do good and act in the best interest of the client, which includes finding alternatives to restraints that promote dignity.
B. Justice refers to fairness in distributing resources and treatment, which does not directly apply in this scenario.
C. Autonomy involves respecting a client’s right to make decisions, but the decision in this case is made by the nurse.
D. Nonmaleficence is avoiding harm, which is closely related but not the best choice because beneficence goes beyond avoiding harm—it actively promotes the client's well-being.
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