A client presented to the emergency room by ambulance with complaints of nausea, diaphoresis, SOB, and severe, squeezing chest pain described as "an elephant sitting on his chest. 21 of oxygen via nasal cannula was started in route to the ED. In addition, three doses of nitroglycerin SL. Aspirin 325mg SL and morphine 2 mg IV were administered prior to arrival, without relief. EKG shows ST elevation with a HR 122. BP 156/94, RR 22 and pulse ox 91% A "STEMI Alert" on this is called overhead. The nurse recognizes the priority intervention to treat this client is to:

A. The client will be turned every 2 hours is a general nursing care practice for all immobile clients to prevent pressure injuries, but it is not specific to the protocol surrounding the use of restraints.

B. The client will need to be monitored every one-half hour is incorrect because clients in restraints must be monitored more frequently—typically every 15 minutes, depending on facility policy and client condition, to assess circulation, skin integrity, and psychological well-being.

C. Documentation of the event will include interventions attempted prior to initiating restraints is the correct answer. Before applying restraints, it is a legal and ethical requirement to document all less restrictive interventions that were attempted and found ineffective. This ensures that restraints are used only as a last resort and that the client's rights and safety are protected.

D. The physician must be present at the time of the restraint episode is incorrect. While a physician's order is required for restraint use, the physician does not need to be physically present at the time of application. However, the physician must conduct a face-to-face evaluation within a specific timeframe, usually within 1 hour of the restraint being applied, depending on regulatory guidelines.

A. Administering aggressive medical interventions to prolong life: In the end stages of Huntington's Disease, aggressive medical interventions are generally not the priority. Huntington's is a progressive neurodegenerative disease, and prolonging life without regard to the patient's quality of life is usually not the focus. The emphasis in end-of-life care is on comfort and symptom management rather than aggressive treatments.

B. Encouraging the patient to engage in physical therapy and exercise: While physical therapy can be important earlier in the disease progression to help maintain function and mobility, in the end stages of Huntington's Disease, the patient's focus is more on comfort care. At this point, physical therapy may not be practical or helpful in improving quality of life, so it is not the primary consideration.

C. Providing comfort care and managing symptoms according to patient's wishes: This is correct. The most important consideration in end-of-life care for a patient with Huntington's Disease is to focus on comfort and symptom management. This includes addressing pain, managing emotional and psychological symptoms, and ensuring that care aligns with the patient's wishes, values, and goals. End-of-life care should prioritize maintaining dignity and ensuring the patient's comfort.

D. Providing respite care and support for the patient's family: While providing respite care and family support are very important aspects of caregiving, the most important consideration is the patient's comfort and managing symptoms in alignment with their wishes. Respite care for the family is important but is not the central focus of end-of-life care for the patient.