A nurse in a primary care provider’s office is caring for a client.

Exhibits

Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again.

Nurses’ Notes

Today, 0900: Client returns for a follow-up examination after new onset of symptoms; client reports loss of appetite; reports sleeping most of the day; became teary when asked about plans for activities; questions reason to live if not working; auscultated lungs for a dry, nonproductive cough; breath sounds present bilaterally; experiences occasional muscle “aches and pains”; reports having no energy.

Choice A Reason:
Keeping the restraints on for a minimum of 1 hour is not a standard practice. The duration of restraint use should be based on the child's behavior and the need for safety, rather than a fixed time period. Restraints should be used for the shortest duration necessary to ensure safety and should be removed as soon as the child is no longer a threat to themselves or others.

Choice B Reason:
Monitoring the child's vital signs every 15 minutes is crucial when a child is in physical restraints. This frequent monitoring helps ensure the child's physical well-being and allows for the early detection of any adverse effects related to the use of restraints. It is important to assess the child's respiratory and cardiovascular status, as well as their overall comfort and safety.

Choice C Reason:
Asking the provider to renew the prescription for the restraints every 24 hours is important, but it is not the most immediate action required. Restraint orders should be reviewed regularly to ensure they are still necessary, but the priority is to monitor the child's condition closely while they are restrained.

Choice D Reason:
Arranging an in-person evaluation by the child's provider within 2 hours of initiating restraints is a good practice to ensure the appropriateness of the restraint use and to reassess the child's condition. However, the immediate priority is to monitor the child's vital signs closely to ensure their safety while restrained.

Choice A Reason:
Offering the medication at the next scheduled dose time respects the client's autonomy and right to refuse treatment. Even though the client is involuntarily admitted, they still retain certain rights, including the right to refuse medication. The nurse should document the refusal and offer the medication again at the next scheduled time, ensuring that the client understands the importance and benefits of the medication. This approach maintains a therapeutic relationship and encourages the client to participate in their own care.

Choice B Reason:
Implementing consequences until the client takes the medication is not an appropriate or ethical approach. This method can be coercive and may damage the therapeutic relationship between the nurse and the client. It is important to respect the client's autonomy and work collaboratively to address their concerns and encourage adherence to the treatment plan.

Choice C Reason:
Administering the medication via IM injection without the client's consent is not appropriate unless there is an immediate risk to the client's safety or the safety of others. Forced medication should only be used as a last resort and in accordance with legal and ethical guidelines. The nurse should first attempt to address the client's concerns and encourage voluntary compliance with the prescribed treatment.

Choice D Reason:
Informing the client that they do not have the right to refuse the medication is incorrect and violates the client's rights. Even involuntarily admitted clients have the right to refuse treatment, except in certain emergency situations where the client poses a danger to themselves or others. The nurse should provide education about the medication and its benefits, and respect the client's decision while continuing to offer support and encouragement.