The nurse is reviewing home medications for a client with a history of Major Depressive Disorder who has been taking sertraline for one year. The client states, “I did research and started taking St. John’s Wort to help with my depression in conjunction with sertraline.” Which of the following should the nurse observe for in the client?

Choice A reason: Acknowledging the client’s excitement avoids the request but doesn’t address boundaries. A clear, professional response about policy maintains trust and safety, making this less effective and incorrect.

Choice B reason: Giving a personal address violates professional boundaries and safety policies. Nurses must maintain privacy, and sharing personal information is inappropriate, making this incorrect and risky.

Choice C reason: A harsh refusal damages therapeutic rapport. While correct about policy, the tone is unprofessional and may alienate the client, making this less appropriate than a polite explanation.

Choice D reason: Politely declining due to hospital policy maintains professionalism and boundaries while appreciating the client’s intent. This fosters trust and adheres to ethical standards, making it the correct response.

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.