A nurse is caring for a client who has physical restraints applied. The nurse determines that the restraints should be removed when which of the following occurs?

The client states that he will harm himself unless the restraints are removed.

The client demonstrates that he is oriented to person, place, and time.

The client is able to follow commands.

The client refuses to take his medication unless he is released.

Answer and Explanation

The Correct Answer is B

A. The client states that he will harm himself unless the restraints are removed.
This statement indicates a clear risk, but merely stating a desire for restraint removal is not sufficient reason to remove restraints. It's essential to assess the patient comprehensively and make the decision based on their current state and safety concerns.

B. The client demonstrates that he is oriented to person, place, and time.
When a restrained patient shows orientation to person (knows who they are and who others are), place (knows where they are), and time (knows the current date and time), it suggests they are aware of their surroundings and can make rational decisions. This orientation indicates a level of awareness that might justify removing the restraints.

C. The client is able to follow commands.
While following commands is an important aspect, it alone might not be enough to guarantee the patient's overall awareness of their situation and safety. A comprehensive assessment, including orientation and ability to follow commands, is necessary.

D. The client refuses to take his medication unless he is released.
Medication refusal alone may not be a sufficient reason to remove restraints, especially if the patient is not demonstrating an understanding of their situation or if releasing the restraints could pose a risk to the patient or others.

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Correct Answer is A

Explanation

A. "This medication is given to help with extrapyramidal side effects."
Benztropine is an anticholinergic medication used to treat the extrapyramidal side effects (EPS) caused by certain psychiatric drugs, particularly antipsychotics. EPS can include symptoms such as muscle stiffness, restlessness, tremors, and other movement disorders. Benztropine helps to alleviate these symptoms, making it an essential medication for individuals experiencing these side effects from antipsychotic medications.

B. "Benztropine helps alleviate your hallucinations."
This statement is incorrect. Benztropine is not primarily used to treat hallucinations; it is used for movement-related side effects as mentioned above.

C. "This medication is given to help with your depression."
This statement is incorrect. Benztropine is not indicated for the treatment of depression.

D. "Benztropine is used to counteract your tachycardia."
This statement is incorrect. Benztropine is not used to treat tachycardia (fast heart rate). It is specifically used for extrapyramidal side effects related to antipsychotic medications.

A. Assess the need for physical restraints. B. Discuss the purpose of the medication with the client. C. Stop the newly licensed nurse from administering the medication. D. Demonstrate how to verbally de-escalate the situation.

Correct Answer is D

Explanation

A. Assess the need for physical restraints:
Assessing the need for physical restraints is not the first action to take in this situation. Physical restraints should only be considered as a last resort when there is an immediate threat to the patient or others. It's essential to attempt verbal de-escalation techniques and other non-coercive interventions before considering physical restraints.

B. Discuss the purpose of the medication with the client:
Discussing the purpose of the medication is an important step, as it can help the client understand why they are being asked to take it. However, it may not be the first action to take, especially if the client is highly agitated or manic. Attempting verbal de-escalation techniques, such as calming communication and active listening, should precede discussing the medication's purpose.

C. Stop the newly licensed nurse from administering the medication:
Stopping the newly licensed nurse from administering the medication without addressing the situation directly doesn't resolve the issue. It's important to equip the nurse with appropriate communication skills to handle the situation effectively. Preventing the administration of the medication is not the primary step; it's more about helping the nurse manage the situation appropriately.

D. Demonstrate how to verbally de-escalate the situation:
This is the recommended first action. Demonstrating verbal de-escalation techniques is crucial when dealing with an agitated or manic patient. The nurse manager can model effective communication strategies to help the newly licensed nurse manage the situation without resorting to physical interventions or restraints. Effective verbal de-escalation can lead to a more peaceful resolution and, ideally, the patient's acceptance of the medication without confrontation.

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A nurse is caring for a client who has physical restraints applied. The nurse determines that the restraints should be removed when which of the following occurs?

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