A charge nurse making rounds observes that an assistive personnel has applied wrist restraints to a client who is agitated and does not have a prescription for restraints. Which of the following actions should the nurse take first?
Review the chart for nonrestraint alternatives for agitation
Inform the unit manager of the incident
Speak with the AP about the incident
Remove the restraints from the client’s wrists
The Correct Answer is D
a. Review the chart for nonrestraint alternatives for agitation:
This action involves assessing the client's history, current condition, and any documented alternatives to restraints for managing agitation. While exploring nonrestraint interventions is important, addressing the immediate issue of inappropriate restraint use should take precedence.
b. Inform the unit manager:
Notifying the unit manager about the incident is important for escalating the situation and involving higher-level management in addressing the inappropriate use of restraints. However, before escalating, the immediate needs of the client should be addressed.
c. Speak with the AP about the incident:
Engaging in a conversation with the assistive personnel (AP) who applied the restraints allows for clarification of the situation, identification of any misunderstandings or training needs regarding restraint use, and immediate removal of the restraints if necessary. However, ensuring the client's safety should be the first priority.
d. Remove the restraints from the client’s wrist:
In situations where restraints are applied without a prescription or appropriate authorization, it is crucial to remove the restraints promptly to prevent potential harm to the client. However, it is essential to address the root cause of the inappropriate use of restraints and ensure that the client receives appropriate care and monitoring following restraint removal.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
a. Transport the client to the operating room without verifying informed consent:
This option suggests an urgent response, prioritizing the immediate need for surgery over the formal process of obtaining informed consent. In certain emergency situations, such as when a patient's life or health is in imminent danger and obtaining consent is not feasible, healthcare providers may proceed with treatment or surgery to prevent further harm or loss of life. However, this approach should be guided by established protocols, legal considerations, and the principle of providing the best possible care for the patient.
b. Delay the surgery until the nurse can obtain informed consent:
This option advocates for ensuring that the patient's autonomy and rights are respected by obtaining informed consent before proceeding with surgery. While obtaining consent is essential, delaying surgery may not always be feasible or advisable in emergency situations where prompt intervention is necessary to prevent deterioration of the patient's condition. However, if circumstances allow, making efforts to obtain informed consent is ethically and legally preferable.
c. Obtain telephone consent from the facility administrator before the surgery:
This option proposes seeking consent from a designated authority within the healthcare facility, such as a facility administrator, via telephone. While this approach may be practical in some cases, it may not always be sufficient to ensure that the patient's rights are fully respected, particularly if the administrator does not have the legal authority to provide consent on behalf of the patient. In emergency situations, obtaining consent from a legally authorized representative of the patient, if available, is generally preferred.
d. Ask the anesthesiologist to sign the consent:
This option involves delegating the responsibility of signing the consent form to another member of the healthcare team, in this case, the anesthesiologist. However, consent for surgery should ideally be obtained directly from the patient or their legally authorized representative, as they are the ones who have the right to make decisions about their medical care. Relying on another healthcare provider to sign the consent form may not adequately protect the patient's autonomy and legal rights.
Correct Answer is B
Explanation
a. Occupational therapy: Occupational therapists focus on helping clients develop, recover, or maintain daily living and work skills. They can assist with adapting the home environment for safety and independence but do not typically arrange for durable medical equipment like wheelchairs.
b. Social services: Correct. Social services can help coordinate the provision of durable medical equipment such as wheelchairs. They can assist with arranging the delivery of the equipment, addressing insurance or financial concerns, and connecting the client with community resources and support services.
c. Home health: Home health services can provide ongoing medical care and assistance at home, but they do not typically handle the logistics of securing durable medical equipment like wheelchairs. They might recommend or facilitate a referral to social services for this need.
d. Physical therapy: Physical therapists help clients regain strength and mobility and may train clients on how to use a wheelchair effectively, but they do not typically arrange for the provision of the wheelchair itself.
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