A nurse is caring for a client who became physically aggressive and had to be placed in mechanical restraints. Which of the following actions should the nurse take while the client is in restraints?

Choice A reason: A speech-language pathologist assesses swallowing difficulties, recommending safe feeding techniques for dysphagia, critical for preventing choking and aspiration in older adults. This referral ensures tailored interventions, essential for nutritional safety, reducing pneumonia risk, and supporting quality of life in long-term care settings.

Choice B reason: Occupational therapists address functional skills, not primarily swallowing, which is managed by speech-language pathologists for dysphagia. Assuming their role risks delayed swallowing assessment, potentially increasing choking risk, critical to avoid in ensuring safe eating for older adults in long-term care facilities.

Choice C reason: Respiratory therapists manage breathing issues, not swallowing difficulties, which require a speech-language pathologist for dysphagia. Assuming their involvement risks missing specialized swallowing care, potentially leading to aspiration, critical to prevent in ensuring safe nutrition for older adults with choking risks.

Choice D reason: Social workers address psychosocial needs, not swallowing issues, managed by speech-language pathologists for dysphagia. Assuming their role risks neglecting physical swallowing assessment, increasing choking or aspiration risk, critical to avoid in ensuring safe meal management for older adults in long-term care.

Choice A reason: A blister-like area is not indicative of a positive Mantoux test, which shows induration; blisters suggest irritation. Assuming blisters are positive risks misdiagnosis, potentially missing tuberculosis exposure, critical to avoid in ensuring accurate screening and follow-up in clients tested for TB.

Choice B reason: Ecchymosis (bruising) is not a positive Mantoux result; induration indicates exposure. Assuming ecchymosis is positive risks incorrect interpretation, potentially overlooking tuberculosis risk, critical to prevent in ensuring proper screening, diagnosis, and follow-up for clients undergoing TB skin testing.

Choice C reason: A cool, blanched area suggests no reaction, not a positive Mantoux test, which requires induration. Assuming blanching is positive risks missing exposure, critical to avoid in ensuring accurate tuberculosis screening, guiding appropriate diagnostic follow-up, and protecting client and public health.

Choice D reason: An elevated, hardened area (induration) at 72 hours indicates a positive Mantoux test, suggesting TB exposure, requiring further evaluation. This is critical for accurate screening, ensuring timely diagnosis, preventing disease spread, and guiding follow-up in clients tested for tuberculosis exposure.