A charge nurse making rounds observes that 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

Speak with the AP about the incident

Remove the restraints from the client’s wrist

Answer and Explanation

The Correct Answer is D

a.   Review the chart for nonrestraint alternatives for agitation: While reviewing alternatives is important, the immediate concern is ensuring the safety and well-being of the client by removing the restraints.
b.   Inform the unit manager: While it's important to inform the unit manager, the first action should be to address the immediate safety issue by removing the restraints.
c.   Speak with the AP about the incident: While it's important to discuss the incident with the assistive personnel, the first priority is to remove the restraints to prevent harm to the client.
d.   Remove the restraints from the client’s wrist: This is the correct action to take first to ensure the client's safety and prevent further harm. Afterward, the nurse can address the situation with the assistive personnel and review alternatives for managing the client's agitation.

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Correct Answer is C

Explanation

a. Delaying the client's discharge without exploring other options may not address the partner's concerns and could lead to further issues.
b. While placing the client in a long-term care facility may be an option, it should be discussed with the case manager and considered alongside other options.
c. Contacting the case manager is appropriate to discuss the partner's concerns and explore alternative discharge arrangements that meet the client's needs.
d. Requesting another family member to assist may not be feasible or address the partner's ability to provide care.

A. Occupational therapy B. Social services C. Home health D. Physical therapy

Correct Answer is B

Explanation

a. Occupational therapy focuses on assisting individuals in performing activities of daily living and may not directly address wheelchair mobility needs.
b. Social services may provide assistance with community resources and support including sourcing for a wheelchair.
c. Home health services may provide skilled nursing care in the home but may not directly address wheelchair mobility needs.
d. Physical therapy specializes in mobility and rehabilitation but arent the best placed to provide the client with resources on access to a wheelchair.

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A charge nurse making rounds observes that 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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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