A nurse on a mental health unit placed a client in mechanical restraints after the client assaulted another client.
Which of the following actions should the nurse take?

Request that the provider renew the prescription for restraints every 8 hr.

Have the provider assess the client within 1 hr after applying the restraints.

Evaluate the client hourly while the restraints are applied.

Obtain a prescription for restraints on an as-needed basis.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Requesting that the provider renew the prescription for restraints every 8 hours is not the best approach. The nurse should follow the facility's policies and protocols for the use of restraints, and these policies typically require that the provider assess the client within a specific timeframe after applying restraints. The provider's assessment should occur promptly to determine the client's continued need for restraints and to address the client's safety and well-being.

Choice C rationale:

Evaluating the client hourly while the restraints are applied is not sufficient. While it's important to monitor the client, especially in terms of circulation and comfort, the provider's assessment should take place within a shorter timeframe, typically within one hour after applying the restraints. Hourly evaluations alone may not be timely enough to address the client's condition and the necessity of the restraints.

Choice D rationale:

Obtaining a prescription for restraints on an as-needed basis is not an appropriate approach. Restraints should only be used when necessary to ensure the safety of the client or others, and their use should be based on a specific assessment by the provider. Using restraints on an as-needed basis without a clear prescription can lead to ethical and legal issues and should be avoided.

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Correct Answer is A

Explanation

Choice A rationale:

The nurse should ask the client, "How have you dealt with similar situations in the past?" This question is essential to assess the client's personal coping skills. By inquiring about the client's previous experiences in handling similar situations, the nurse can gain insight into the client's coping mechanisms and identify potential strengths and weaknesses. Understanding how the client has coped in the past can help tailor interventions and support to their specific needs.

Choice B rationale:

While asking, "Can you describe how you are currently feeling?" is a valuable question, it primarily focuses on the client's current emotional state and may not provide a comprehensive assessment of their coping skills. It is crucial to understand the client's emotions, but it does not directly address their coping strategies.

Choice C rationale:

"Do you see your current situation affecting your future?" is a forward-looking question that explores the client's perception of how their current situation might impact their future. While this question is relevant, it does not directly assess the client's coping skills and strategies. It focuses more on the client's expectations and outlook.

Choice D rationale:

"How does this situation affect your life?" is a broad question that can provide insights into the client's life and the impact of their current situation. However, it does not specifically address the client's coping skills and strategies. It may provide information about the consequences of their situation but not their ability to cope.

A. Justice. B. Beneficence. C. Autonomy. D. Veracity.

Correct Answer is C

Explanation

Choice A rationale:

Justice refers to the fair and equitable distribution of resources and treatment, and it doesn't directly apply to the nurse supporting the client's refusal of medications.

Choice B rationale:

Beneficence involves the promotion of the client's well-being and may sometimes conflict with the client's autonomy when they refuse treatment. This choice doesn't apply to the situation where the nurse supports the client's decision to refuse medications.

Choice C rationale:

Autonomy is the ethical principle that supports an individual's right to make decisions about their own care, even if those decisions go against medical advice. In this scenario, the nurse is respecting the client's autonomy by supporting their choice to refuse medications.

Choice D rationale:

Veracity involves truth-telling and honesty in the nurse-client relationship. While it is essential, it is not the primary ethical principle being displayed when the nurse supports the client's refusal of medications.

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A nurse on a mental health unit placed a client in mechanical restraints after the client assaulted another client.Which of the following actions should the nurse take?

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A nurse on a mental health unit placed a client in mechanical restraints after the client assaulted another client.
Which of the following actions should the nurse take?