A nurse is assessing a client following treatment for serotonin syndrome caused by an antidepressant medication. Which of the following findings indicates the treatment has been effective?

A. An assistive personnel reapplies a soft limb restraint on a client after assisting them to the bathroom: Reapplying a soft limb restraint in itself does not necessarily require an incident report. However, the application must follow proper protocols, and the nurse should ensure that the assistive personnel are trained and following the correct procedures.
B. An assistive personnel applies physical restraints on a client who is aggressive: Physical restraints should only be applied with a physician's order and in accordance with facility policies. If restraints are applied without proper authorization or protocol, an incident report must be completed.
C. An assistive personnel tells the provider that a client is making other clients feel unsafe: Reporting concerns to the provider about a client's behavior is part of proper communication and does not require an incident report.
D. An assistive personnel provides 1:1 monitoring for a client who is reporting thoughts of self-harm: This is an appropriate and necessary intervention for a client at risk of self-harm. It does not require an incident report, as the staff member is performing their duty to ensure the safety of the client.

A. Call security guards to the scene for a show of force: Calling security may escalate the situation, especially if the client is already showing signs of agitation. This could increase fear or aggression, making it harder to de-escalate the client. A calm and supportive approach is more effective.
B. Escort the client to a secluded area to speak privately: Escorting the client to a secluded area may increase feelings of isolation or entrapment, potentially worsening the situation. It is better to maintain an open, non-threatening environment for communication and de-escalation.
C. Offer the client several options for a time-out period: Offering choices, such as a time-out, helps the client feel some control over the situation, which can reduce agitation. This strategy fosters cooperation while addressing the need for the client to calm down in a safe space.
D. Place the client in restraints before they escalate further: Restraints should be a last resort and only used if the client poses an immediate danger to themselves or others. Using restraints prematurely can increase aggression and escalate the situation, so other de-escalation techniques should be tried first.