A nurse enters a client's room and sees smoke coming from a wall outlet.
After removing the client from the room, which of the following actions should the nurse take next?

Choice A rationale

Applying wrist restraints immediately is an invasive intervention that may escalate the client’s agitation and anger. Restraints are used when absolutely necessary to prevent harm, and only after other de-escalation techniques have failed. Their use may breach the least restrictive intervention principle, which prioritizes non-invasive measures first.

Choice B rationale

Engaging the client in a repetitive activity acts as a distraction and can reduce agitation by refocusing their attention. This technique aligns with dementia care principles, emphasizing non-pharmacological interventions to manage behavioral disturbances. By promoting sensory engagement, it can help mitigate aggression effectively and respectfully.

Choice C rationale

Placing the client in a seclusion room can escalate feelings of confusion, isolation, and fear, worsening agitation. Seclusion should only be a last resort for safety reasons and not a first-line intervention in dementia care. It is contraindicated unless immediate harm is likely.

Choice D rationale

Administering haloperidol without first attempting non-pharmacological interventions disregards the principle of using medications judiciously. While haloperidol may calm agitation, side effects such as sedation or movement disorders make it inappropriate as a first-line option. This choice should follow other measures.

Choice A rationale

Calling the surgeon to explain the procedure ensures that the client's Questions are addressed by the appropriate professional with the required expertise. This action complies with informed consent principles and prioritizes patient autonomy and understanding, essential for ethical care.

Choice B rationale

Documenting the client's concerns is important for continuity of care but does not directly address the client's need for information. Immediate action to provide clarity from the surgeon is required to ensure the client's understanding and confidence before proceeding.

Choice C rationale

Providing written materials offers supplementary information but does not replace the direct explanation needed to clarify the client's Questions. Effective communication must be verbal and tailored to address the client's specific concerns comprehensively.

Choice D rationale

Reassuring the client and proceeding with preparation overlooks their need for additional clarification. It compromises the ethical standard of informed consent, which necessitates that the client fully understands the procedure before any preparatory actions are taken.