A nurse is caring for a client.

Exhibits

The nurse is collecting data from the client 12 hr. later. How should the nurse interpret the following findings?
For each potential finding, specify whether the finding is an indication of potential improvement or an indication of potential worsening condition.

Choice A Reason: Document the client's behavior in the medical record every 1 hour.

This statement is correct. When a client is placed in restraints, it is crucial to monitor and document their behavior and condition regularly. According to guidelines, the client's behavior, physical condition, and the need for continued restraint should be documented at least every hour. This documentation helps ensure the client's safety and provides a record of the care provided, which is essential for legal and medical purposes.

Choice B Reason: Provide range of motion exercises to all extremities every 2 hours.

This statement is also correct. Clients in restraints should receive range of motion exercises to prevent complications such as muscle atrophy, joint stiffness, and circulation problems. These exercises should be performed at least every 2 hours to maintain the client's physical health and comfort. However, this action alone does not address the comprehensive monitoring required for a client in restraints.

Choice C Reason: Keep staff interactions with the client to a minimum.

This statement is incorrect. While it is important to avoid overstimulating or agitating the client, minimizing staff interactions is not advisable. Regular interactions are necessary to assess the client's condition, provide care, and ensure their safety. Staff should engage with the client in a calm and supportive manner, ensuring that the client feels monitored and cared for.

Choice D Reason: Request the provider renew the prescription in 24 hours.

This statement is incorrect. Restraint orders must be reviewed and renewed more frequently than every 24 hours. Typically, the provider must evaluate the need for continued restraint within a shorter timeframe, such as every 4 hours for adults. This frequent review ensures that restraints are used only as long as absolutely necessary and that the client's condition is regularly reassessed.

Choice A reason:
Chewing sugar-free gum several times daily is generally safe and can help manage dry mouth, a common side effect of haloperidol decanoate. Dry mouth occurs because haloperidol can reduce saliva production. Sugar-free gum stimulates saliva flow, which can alleviate this discomfort. Therefore, this statement does not need to be addressed by the nurse.

Choice B reason:
Spending several hours a day outside gardening when it's sunny should be addressed by the nurse. Haloperidol can make the skin more sensitive to sunlight, increasing the risk of sunburn. Clients taking haloperidol should be advised to use sunscreen, wear protective clothing, and limit sun exposure to prevent skin damage. This is particularly important for those who spend extended periods outdoors.

Choice C reason:
Checking blood pressure once a week is a good practice, especially for clients on antipsychotic medications like haloperidol, which can affect cardiovascular health. Regular monitoring helps in early detection of any adverse effects on blood pressure, allowing for timely intervention. This statement does not need to be addressed by the nurse.

Choice D reason:
Avoiding alcohol is important for clients taking haloperidol decanoate. Alcohol can interact with haloperidol, potentially increasing the risk of side effects such as drowsiness, dizziness, and impaired motor coordination. The client's statement indicates adherence to this important guideline, so it does not need to be addressed by the nurse.