A nurse is caring for a client who has alcohol use disorder. Which of the following statements made by the client indicates the client has a support system?

A. Document the client's behavior hourly on a flow sheet: While documentation is important, it is more frequent than hourly. Clients in restraints should be observed and documented on more frequently, usually every 15 minutes to ensure safety and assess the client's condition.

B. Request a PRN client prescription for restraints from the provider: Restraints require a specific order from the provider, not a PRN (as needed) prescription. The order must be obtained initially and renewed per the facility's policy, typically every 24 hours.

C. Observe the client's behavior once every 15 minutes: Clients in restraints must be closely monitored for safety and well-being. The nurse should assess the client’s condition, including physical and emotional status, every 15 minutes.

D. Remove the restraint when the client calmly follows commands: Restraints should only be removed under appropriate conditions as assessed by the nurse, and with a provider’s order when necessary. The client's behavior alone does not determine the removal of restraints.

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.