A nurse is caring for a client who is aggressive toward other clients and has been placed in wrist restraints. After obtaining a prescription for restraints from the provider, which of the following actions should the nurse take?

Document the client’s behavior once every hour.

Keep the client in restraints until the prescription expires.

Conduct a debriefing regarding the client with the unit staff.

Request an evaluation of the client within 12 hours of application of restraints.

Answer and Explanation

The Correct Answer is D

Choice A reason: Documenting the client’s behavior once every hour is important for monitoring the client’s condition and ensuring their safety. However, it is not the most immediate action to take after applying restraints.

Choice B reason: Keeping the client in restraints until the prescription expires is not appropriate. Restraints should be used for the shortest duration necessary and should be removed as soon as the client is no longer a threat to themselves or others.

Choice C reason: Conducting a debriefing with the unit staff is important for reviewing the incident and planning future care. However, it is not the immediate action required after applying restraints.

Choice D reason: Requesting an evaluation of the client within 12 hours of applying restraints is crucial. This ensures that the client’s condition is reassessed, and the need for continued restraints is evaluated. It also helps in planning further interventions to manage the client’s aggressive behavior.

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Correct Answer is B

Explanation

Choice A reason:

Giving the client a cup of hot black tea before bed is not advisable. Black tea contains caffeine, which can interfere with sleep and exacerbate sleep disturbances. It is important to avoid stimulants before bedtime to promote better sleep quality.

Choice B reason:

Waking the client at the same time each morning helps establish a consistent sleep-wake cycle, which is beneficial for managing sleep disturbances. Regular wake times can help regulate the body’s internal clock and improve overall sleep patterns.

Choice C reason:

Taking the client for a walk 2 hours before bedtime can be beneficial as physical activity can promote better sleep. However, it is not as crucial as maintaining a consistent wake time, which directly influences the sleep-wake cycle.

Choice D reason:

Allowing the client to take a 90-minute nap immediately after lunch may interfere with nighttime sleep. Long naps during the day can reduce the drive to sleep at night, leading to further sleep disturbances.

A. A nurse did not clarify a client’s prescription that was difficult to read resulting in a medication error. B. A nurse posted private information on social media about a client who has substance use disorder. C. A nurse placed a client in mechanical restraints without obtaining a prescription, resulting in injury. D. A nurse threatened a client with physical harm after the client became verbally abusive to staff members.

Correct Answer is A

Explanation

Choice A reason:

An unintentional tort occurs when a healthcare provider’s actions or inactions cause harm to a patient without intent to harm. In this scenario, the nurse’s failure to clarify a difficult-to-read prescription, resulting in a medication error, is an example of negligence, which is an unintentional tort.

Choice B reason:

Posting private information about a client on social media is a breach of confidentiality and an intentional tort. This action is deliberate and violates the client’s right to privacy.

Choice C reason:

Placing a client in mechanical restraints without obtaining a prescription, resulting in injury, is an intentional tort. This action involves a deliberate decision to restrain the client without proper authorization, leading to harm.

Choice D reason:

Threatening a client with physical harm is an example of assault, which is an intentional tort. This involves a deliberate act to cause the client to fear imminent harm.

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A nurse is caring for a client who is aggressive toward other clients and has been placed in wrist restraints. After obtaining a prescription for restraints from the provider, which of the following actions should the nurse take?

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