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 D
Explanation
A. "I am trying to help you, but you haven't told me why you are overwhelmed yet." This response sounds dismissive and places responsibility on the client, which may increase their frustration.
B. "Have you tried to avoid the situations that are causing you so much stress?" Avoidance is not a healthy coping mechanism and does not encourage the client to express their feelings.
C. "Tell me about what you are doing to reduce or cope with your stress." While this encourages self-reflection, it does not validate the client’s distress or express empathy.
D. "I would like to help you. Can you tell me more about what you are feeling?" This response shows empathy, offers support, and invites the client to express their emotions, which are key aspects of therapeutic communication.
Correct Answer is B
Explanation
A. The nurse describes what happened by providing general and broad details. Incident reports should be factual, objective, and specific, not general or vague.
B. The nurse includes the client's own words when describing what happened. Including direct quotes from the client ensures accuracy and avoids interpretation or bias.
C. The nurse describes what happened subjectively. Incident reports must be objective, avoiding personal opinions or assumptions.
D. The nurse includes the opinions of other team members. Only document observable facts and direct quotes—opinions should not be included.
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