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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Controlled coughing increases intrathoracic pressure, worsening ICP by impeding cerebral venous return. This is contraindicated, making it incorrect compared to measures that reduce ICP like bed elevation.
Choice B reason: Elevating the head of the bed to 30 degrees promotes venous drainage, reducing ICP. This is a standard intervention for managing increased ICP, making it the correct action for the client.
Choice C reason: Encouraging 2000 mL fluid intake risks fluid overload, increasing ICP. Fluid restriction may be needed, making this incorrect for managing a client with elevated intracranial pressure.
Choice D reason: A brightly lit environment can increase agitation, potentially raising ICP. A calm, dim setting is preferred, making this incorrect compared to elevating the head to reduce pressure.
Correct Answer is C
Explanation
Choice A reason: Obstructive sleep apnea causes interrupted breathing during sleep, leading to fatigue, irritability, and potential cognitive impairment. While chronic sleep disruption may contribute to mood changes, it is not typically associated with aggressive or self-injurious behaviors. These behaviors are more characteristic of neurodevelopmental or psychiatric disorders, making sleep apnea an unlikely primary cause in this scenario, as it primarily affects sleep quality and daytime alertness.
Choice B reason: Insomnia involves difficulty falling or staying asleep, which can lead to irritability, fatigue, and emotional dysregulation. However, it is not directly linked to aggressive or self-injurious behaviors, which are more commonly associated with neurodevelopmental conditions like autism or psychiatric disorders. Insomnia may exacerbate underlying issues but is not a primary cause of such behaviors in this context.
Choice C reason: Autism spectrum disorder is characterized by challenges with social communication, sensory sensitivities, and emotional regulation, which can manifest as aggression or self-injurious behaviors, particularly under stress or sensory overload. These behaviors may occur due to difficulties processing emotions or environmental stimuli, making autism a likely diagnosis for the client’s presentation, requiring targeted behavioral and therapeutic interventions.
Choice D reason: Narcolepsy involves excessive daytime sleepiness and sudden sleep attacks due to dysregulation of sleep-wake cycles. It does not typically cause aggressive or self-injurious behaviors, as its primary symptoms are related to sleep disturbances. These behaviors are more aligned with neurodevelopmental or psychiatric conditions, ruling out narcolepsy as a likely cause of the client’s aggressive and self-injurious actions.
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