A nurse is admitting a client who has pneumonia. The nurse should initiate which of the following isolation precautions for the client?

A.PRN (as needed) restraint prescriptions are not appropriate because restraints should only be used in situations where there is an immediate need for safety and all other methods of de-escalation have failed. Restraint use must be based on a current assessment of the client's behavior, and a specific prescription should be obtained each time restraints are applied.

B.Restraints should be removed every 2 hours to assess the client's skin, circulation, and range of motion, and to provide an opportunity for toileting, hydration, and movement. Prolonged use without breaks increases the risk of complications such as skin breakdown or impaired circulation.

C.Attach the restraint to the bed's side rails. Restraints should not be attached to the bed's side rails because it can lead to serious injuries if the client attempts to climb over the side rails while restrained. Instead, restraints should be attached to specific restraint ties or straps that are part of the bed frame.

D.The client's condition, including circulation, skin integrity, and behavior, should be monitored and documented every 15 minutes while restraints are in use. This frequent assessment helps ensure the client’s safety and comfort, and allows for early identification of potential complications.

A. "I'm sure your family does not want you to die." is not a therapeutic response, as it invalidates the client's feelings and imposes the nurse's own assumptions. This choice is incorrect.

B. Why would you believe such things?" is not a therapeutic response, as it sounds judgmental and confrontational, which can increase the client's defensiveness and resistance. This choice is incorrect.

C. "How does this make you feel?" is a therapeutic response, as it encourages the client to express and explore their emotions, which can help to build rapport and trust with the nurse. This choice is correct.

D. "You should talk to your family about your feelings." is not a therapeutic response, as it implies that the client is responsible for resolving their own problems and that their family is willing and able to listen and support them, which may not be true. This choice is incorrect.