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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?

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.

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 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.

The correct answer is: b) An 8-year-old child is asked to return to their room after yelling at other children during a group therapy session.

Answer and Explanation

The Correct Answer is B

Choice A reason: Administering clozapine, an antipsychotic, is a restrictive intervention due to its pharmacological impact on dopamine and serotonin receptors, altering brain function. Used for severe aggression, it involves significant side effects (e.g., agranulocytosis), making it more restrictive than non-pharmacological options, as it alters the client’s mental state and requires monitoring.

Choice B reason: Asking a child to return to their room after yelling is the least restrictive alternative, as it involves verbal guidance without physical or pharmacological intervention. This approach allows de-escalation in a safe environment, addressing behavior driven by emotional dysregulation without invasive measures, preserving autonomy and safety.

Choice C reason: Physical restraints are highly restrictive, limiting movement and autonomy, and are used only in extreme cases to prevent harm. They can cause physical and psychological trauma, increasing stress hormone release (e.g., cortisol), and are far more invasive than verbal redirection, making them a highly restrictive intervention.

Choice D reason: Taking an adolescent to a secure quiet room is a restrictive measure, as it isolates the client and limits freedom, though less invasive than restraints or medication. It addresses aggressive behavior potentially linked to heightened amygdala activity but is more restrictive than verbal redirection, as it physically removes the client from the environment.

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Correct Answer is C

Explanation

Choice A reason: Wearing an eye patch at all times for diplopia in multiple sclerosis is inappropriate, as it may not address the underlying demyelination causing visual disturbances. Alternating eye patches or consulting a neurologist is preferred, as constant patching could strain vision or mask worsening symptoms, reducing quality of life.

Choice B reason: Relaxing in a hot tub daily is not advisable for multiple sclerosis, as heat can exacerbate symptoms (Uhthoff’s phenomenon) by slowing nerve conduction in demyelinated areas. This could worsen fatigue, sensory changes, or motor symptoms, making it an unsafe recommendation for managing MS symptoms.

Choice C reason: Implementing a rest schedule is appropriate for multiple sclerosis, as fatigue is a common symptom due to immune-mediated demyelination and central nervous system dysfunction. Rest periods help conserve energy, reduce symptom exacerbation, and improve daily functioning, making this a critical strategy for managing MS effectively.

Choice D reason: A vigorous exercise program is inappropriate for MS clients with active symptoms like diplopia and sensory changes, as overexertion can worsen fatigue and neurological symptoms. Gentle, tailored exercise may be beneficial, but vigorous activity risks exacerbating demyelination-related impairments, making this an unsuitable recommendation.

A. Traumatic B. Anticipatory C. Complicated D. Disenfranchised

Correct Answer is B

Explanation

Choice A reason: Traumatic grief follows sudden, violent loss, not a terminal illness with expected death. The client’s situation involves forewarning, making anticipatory grief more fitting, so this is incorrect.

Choice B reason: Anticipatory grief occurs before an expected loss, as in terminal cancer, where clients and families prepare emotionally. This aligns with the situation, making it the correct type of grief.

Choice C reason: Complicated grief involves prolonged, impairing mourning after loss, not before. The client is still alive, so anticipatory grief is current, making this incorrect for the scenario.

Choice D reason: Disenfranchised grief is unacknowledged loss, like miscarriage. Terminal cancer is socially recognized, so anticipatory grief fits better, making this incorrect for the client’s experience.

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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 is presenting discharge instructions to a client who has multiple sclerosis (MS). The client reports symptoms of diplopia and sensory change. Which of the following nursing statements are appropriate?

Correct Answer is C

Explanation

A nurse is caring for a client who has cancer and is terminally ill. The nurse should recognize that the client and their family might be experiencing which of the following types of grief?

Correct Answer is B

Explanation

A nurse on a mental health unit is caring for a client who has generalized anxiety disorder. The client received a telephone call that was upsetting and now the client is pacing up and down the corridors of the unit. Which of the following actions should the nurse take?

A nurse is planning a unit orientation for a newly admitted client who has severe depression. Which of the following should be the nurse’s approach?

A nurse is providing care to a client who is aggressive and demonstrating self-injurious behaviors. Which of the following disorders does the nurse identify as being consistent with this behavior?

A nurse is observing a group therapy session. Which of the following client statements should the nurse identify as an indication of bulimia nervosa?

A nurse is caring for a client 3 days after admission for treatment of depression. The client leaves her current activity, approaches the nurse, and states, “There’s no reason to go on living. I just want to end it all.” Which of the following actions should the nurse take?

The nurse is setting up the room for an admission who is being admitted for alcohol withdrawal. Which of the following should the nurse place at bedside to initiate seizure precautions? (Select all that apply)

A nurse is caring for a client who states, “I did not take my medication because my partner forgot to remind me.” The nurse should identify that the client is demonstrating which of the following defense mechanisms?

A nurse is caring for a group of clients at a mental health facility. The nurse should identify that which of the following clients is exhibiting a warning sign of suicide?