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 D

Explanation

a. While limited social support is important to address for a successful discharge plan, it may not be as urgent as addressing issues directly related to the client's recovery from surgery.
b. Decreased self-esteem is a significant concern but may not directly impact the client's immediate postoperative recovery and discharge plan.
c. Inadequate food supply is important to address for the client's overall well-being but may not be as urgent as addressing issues directly related to the client's recovery from surgery.
d. Low pain tolerance can significantly affect the client's recovery process and may require immediate attention to ensure adequate pain management postoperatively.

A. Whether the client understands the risk of refusing the procedure B. Whether the partner is the client's durable power of attorney for health care C. Whether the client's refusal is based on a religious belief D. Whether the facility ethics committee reaches a consensus on the case

Correct Answer is A

Explanation

A: The autonomy of the patient is paramount in medical ethics. If the client understands the risks and still refuses the procedure, their choice must be respected. It is a fundamental right for patients to make informed decisions about their own healthcare.

B: While a durable power of attorney for health care is crucial when a patient is incapacitated, it does not override the wishes of a competent patient. As long as the client is capable of making decisions, their consent is required for any procedure.

C: Although religious beliefs are respected, they do not serve as the primary deciding factor if the client is competent. The client's understanding and decision-making capacity are the key determinants in whether to proceed with the surgery.

D: The ethics committee can provide guidance on complex cases, but it cannot make decisions for a competent patient. The committee's role is advisory, and the final decision rests with the patient.

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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?

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