A nurse in the emergency department (ED) is caring for a client.

Click to highlight the findings that indicate the client is malnourished. To deselect a finding, click on the finding again.

A. Encourage the client to relax and take deep breaths during the dressing change: While relaxation and deep breathing can help reduce anxiety and provide some comfort, they do not address the root cause of the client’s pain. Non-pharmacologic measures alone are insufficient when a procedure is known to cause significant procedural pain, making this supportive but not priority.

B. Educate the client about the importance of the dressing change to prevent infection: Patient education is important for adherence and understanding the purpose of care. However, explaining the procedure does not relieve the client’s current pain, and the client may not be able to tolerate the dressing change without adequate analgesia.

C. Assist the client to a comfortable position for the dressing change: Positioning can help reduce discomfort and facilitate access to the surgical site, but it does not eliminate procedural pain. Although this action is supportive and appropriate, it is not the most effective way to prevent or control pain during the dressing change.

D. Administer pain medication 45 min before changing the client's dressing: Administering analgesia prior to a painful procedure is the priority action according to the principles of pain management. Timing the medication to ensure peak effect during the dressing change minimizes procedural pain, improves patient cooperation, and supports overall recovery.

Rationale for correct choices

• Review medications that might be causing confusion: Before initiating restraints, the nurse should first assess for reversible causes of the client’s confusion. Certain medications, especially sedatives or antiemetics, can contribute to altered mental status in acutely ill clients. Identifying medication-related causes allows the healthcare team to adjust therapy and potentially resolve the confusion without restrictive measures.

• Using other methods to keep the client safe: Restraints are considered a last resort and should only be used after less restrictive interventions have been attempted. Alternative safety measures include frequent reorientation, close observation, moving the client closer to the nurses’ station, or using bed alarms. These interventions promote safety while preserving the client’s dignity and autonomy.

Rationale for incorrect choices

• Obtain a prescription from the provider for restraints: A provider’s prescription is required for restraints, but it should only be requested after other safety interventions have failed. The nurse must first assess contributing factors and attempt less restrictive methods. Jumping immediately to restraints can increase agitation, risk injury, and violate restraint guidelines.

• Assess where the restraints will be placed on the client: Assessment of placement sites is necessary if restraints are eventually applied to prevent skin injury or impaired circulation. However, this step occurs only after the decision to use restraints has been made. Prioritizing this assessment before attempting alternatives would bypass less restrictive safety measures.

• Padding bony prominences under the restraint: Padding protects skin integrity when restraints are in use, but this intervention occurs during restraint application. Since restraints are not yet indicated, padding is not an immediate priority. The nurse must first attempt other safety strategies to prevent harm. Protective padding becomes relevant only if restraints are required.

• Monitoring the client in restraints every 2 hrs: Frequent monitoring is required for clients who are already in restraints to assess circulation, skin condition, and continued need for restraint use. In this scenario, restraints have not been applied. Monitoring requirements apply after restraints are initiated, not before the decision to use them is made.