A nurse is caring for a client who has suspected clonus. Which of the following actions should the nurse take to assess for this condition?

A. Only use restraints if the client becomes violent: Restraints should be used as a last resort when the client poses a danger to themselves or others. They are not meant for convenience or managing disorientation alone.

B. Use seclusion to manage the client's behavior: Seclusion is typically reserved for managing severe aggression or self-harm in psychiatric settings. It is not an appropriate first-line intervention for a disoriented client attempting to get out of bed.

C. Attempt the use of less restrictive methods before using restraints: The nurse should first implement interventions such as frequent monitoring, bed alarms, or sitter assistance. This approach prioritizes client safety while respecting autonomy and minimizing harm.

D. Use restraints for the minimum amount of time necessary: If restraints are applied, they must be removed as soon as it is safe to do so to prevent physical and psychological complications, adhering to best practice and regulatory guidelines.

E. Ensure the restraint limits the client's movement as little as possible: Proper application of restraints focuses on safety while allowing maximum mobility and comfort. Overly restrictive restraints can cause injury, skin breakdown, and additional stress.

A. Move the client using a slider board: A slider board can assist with lateral transfers, but for a client weighing 136 kg (300 lb), it may not provide the safest method due to the increased risk of strain and injury to staff. A more advanced device is preferred.

B. Use an air-assisted transfer device to move the client: An air-assisted transfer device is the safest choice for bariatric clients because it significantly reduces friction, making movement easier and safer for both the client and healthcare workers. It minimizes musculoskeletal injury risk during transfer.

C. Raise the bed to 5 cm (2 in) above the level of the stretcher: The bed should be adjusted to the same height as the stretcher to allow a smooth transfer. Raising it higher can make the transfer unsafe and increase the risk of injury or difficulty sliding the client across.

D. Position the head of the bed at 25° prior to the transfer: The head of the bed should be flat during lateral transfers to maintain spinal alignment and ease movement. Elevating the head complicates the process and increases the chance of shear or strain.