A newly licensed nurse applying prescribed wrist restraints on client. Which of the following actions should the nurse take?

A) Four wheel walker: While a four-wheel walker provides excellent support and stability for clients with significant mobility limitations, it is not always the best choice for someone who occasionally loses balance. It can be bulky and difficult to maneuver in tight spaces, and it may not provide as much support for clients who need only occasional assistance with balance. A gait belt allows for more hands-on assistance when needed.

B) Gait belt: A gait belt is the most appropriate device to use when assisting a client who occasionally loses balance. It allows the nurse to provide hands-on support and maintain the client’s safety during ambulation. The gait belt provides a secure hold, enabling the nurse to assist the client in regaining balance quickly, preventing falls if the client starts to lose their stability.

C) Jacket harness: A jacket harness is typically used in more severe cases of balance loss or in situations where the client has significant mobility impairments. While it provides more overall support, it may not be necessary for a client who only occasionally loses balance. It can also be more cumbersome than a gait belt for helping with short, occasional ambulation.

D) Cane: A cane is helpful for clients who need mild to moderate support while walking, but it might not offer enough stability for a client who occasionally loses balance. A cane may provide support in some cases, but using a gait belt would be more effective for safely supporting and guiding the client during ambulation.

A) Tertiary prevention: Tertiary prevention involves interventions aimed at reducing the long-term effects of a disease or injury, improving quality of life, and preventing further complications. In this case, the patient is receiving rehabilitation services (physical therapy and speech therapy) after a stroke to help restore function, improve mobility, and address communication issues caused by the stroke. This type of care focuses on managing and mitigating the effects of an existing health condition, which aligns with tertiary prevention.

B) Primary prevention: Primary prevention refers to actions taken to prevent the onset of a disease or condition before it occurs, such as immunizations, lifestyle modifications, or education about healthy behaviors. Since the patient has already experienced a stroke, primary prevention is not applicable in this situation.

C) Health promotion: Health promotion involves actions that improve overall health and well-being, such as encouraging healthy lifestyles, providing education, and promoting activities that prevent illness. While health promotion is important, it is not the primary focus in this scenario, as the patient is already dealing with the aftermath of a stroke and is receiving rehabilitation to address the effects of the condition.

D) Secondary prevention: Secondary prevention involves early detection and intervention to prevent the progression of a disease or condition. It typically includes screening and diagnostic procedures to identify diseases in their early stages. Since the patient has already experienced a stroke, secondary prevention is not the appropriate level of care here.