A nurse on a mental health unit is discussing restraints and seclusion with a group of newly hired nurses. At which of the following times should a nurse discuss the restraint and seclusion policy with a client?

When a client becomes agitated.

While administering chemical or physical restraints.

During debriefing after restraint removal.

Upon admission.

Answer and Explanation

The Correct Answer is D

Choice A rationale
While it’s important to discuss the restraint and seclusion policy when a client becomes agitated, it’s not the ideal time. The client may not be in a state to fully understand the information due to their heightened emotional state.
Choice B rationale
Discussing the policy while administering chemical or physical restraints is not appropriate. The client may be distressed or resistant, making it difficult for them to comprehend the information.
Choice C rationale
Although debriefing after restraint removal is a crucial part of the process, it’s not the best time to first introduce the restraint and seclusion policy. The client may be physically and emotionally exhausted after the experience.
Choice D rationale
The restraint and seclusion policy should be discussed with the client upon admission. This ensures that the client is aware of the policy ahead of time, which can help reduce anxiety and fear if restraints or seclusion become necessary.

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Correct Answer is B

Explanation

Choice A rationale
Asking both clients to take a time out in their separate rooms may not be the best first intervention. This approach might not address the root cause of the argument and could potentially escalate the situation if one or both of the residents feel unfairly treated.
Choice B rationale
Distracting the clients by asking them to participate in an activity is the most appropriate first intervention. This approach can help defuse the situation and redirect the residents’ attention away from the argument. It’s a non-confrontational way to de-escalate the situation and can help maintain a peaceful environment in the facility.
Choice C rationale

Sending both clients into seclusion is not an appropriate first intervention. Seclusion should be used as a last resort and only when the residents pose a risk to themselves or others. In this case, the argument does not seem to have escalated to a level that would warrant such a drastic measure.
Choice D rationale
Physically restraining both clients is not an appropriate first intervention. Restraints should only be used as a last resort when there is an immediate risk of harm to the residents or others. In this case, the argument does not seem to have escalated to a level that would warrant physical restraint.

A. Derealization. B. Hypervigilance. C. Dissociative amnesia. D. Depersonalization.

Correct Answer is C

Explanation

Choice A rationale
Derealization involves feeling detached or disconnected from one’s surroundings, not changing details of a traumatic event.
Choice B rationale
Hypervigilance involves being overly alert or watchful, especially to potential danger, not changing details of a traumatic event.
Choice C rationale
Dissociative amnesia can involve difficulty remembering important information about a traumatic event, which can lead to inconsistencies in the child’s recollections.
Choice D rationale
Depersonalization involves feeling detached or disconnected from oneself, not changing details of a traumatic event.

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A nurse on a mental health unit is discussing restraints and seclusion with a group of newly hired nurses. At which of the following times should a nurse discuss the restraint and seclusion policy with a client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a long-term care facility notices two residents arguing in the day room over a game they are playing. Which of the following interventions should the nurse use first?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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