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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Dementia is a progressive cognitive decline that affects memory, reasoning, and behavior. While exhaustion and distraction could be seen in dementia, it is unlikely in an otherwise healthy nurse.

B. Burnout is a state of physical, emotional, and mental exhaustion caused by chronic workplace stress. Symptoms include fatigue, cynicism, reduced effectiveness, and dissatisfaction with work.

C. Traumatic brain injury (TBI) results from a head injury and leads to cognitive and physical symptoms like memory loss, headaches, and coordination issues, which do not align with the scenario.

D. Bipolar disorder involves episodes of mania and depression, not just exhaustion and dissatisfaction. It is a clinical mental health condition, whereas burnout is work-related stress.

A. The client must be calm and cooperative. B. The client must verbalize remorse for their behavior. C. The client only verbalizes anger toward the staff. D. The provider who prescribed the restraints must be present to assess the client before the restraints can be removed.

Correct Answer is A

Explanation

A. The client must be calm and cooperative. Restraints should be removed as soon as the client is calm and no longer poses a threat to themselves or others. Continued use without justification can be considered unethical and unlawful.

B. The client must verbalize remorse for their behavior. Remorse is not a requirement for restraint removal. Some clients may lack insight into their actions due to mental illness or cognitive impairment. The focus should be on safety, not forced expressions of regret.

C. The client only verbalizes anger toward the staff. Expressing anger alone is not a justification for continued restraint. As long as the client is not aggressive or violent, they should not remain restrained.

D. The provider who prescribed the restraints must be present to assess the client before the restraints can be removed. Nurses can remove restraints without the provider physically present if the client meets the criteria for release. However, they must document the assessment and notify the provider.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse notes that a colleague seems exhausted, discouraged, distracted, and expresses dissatisfaction with being a nurse. The nurse should identify these as manifestations of which of the following conditions?

Correct Answer is B

Explanation

A nurse is caring for a client who is in physical restraints after demonstrating aggressive behavior. Which of the following criteria must be met before the nurse can remove the restraints?

Correct Answer is A

Explanation

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