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 hr of application of restraints

Answer and Explanation

The Correct Answer is C

A. Documentation should occur every 15-30 minutes to ensure the client's safety and to assess the need for continuing or removing the restraints.

B. Keep the client in restraints until the prescription expires: Restraints should be used for the shortest duration necessary to ensure the safety of the client and others. Keeping the client restrained until the prescription expires without reevaluation may not align with best practices for restraint use.

C. Conducting a debriefing with the unit staff is crucial to evaluate the situation, discuss the events leading up to the use of restraints, and develop strategies to prevent the need for future restraint use. This helps ensure the safety and well-being of the client and others, as well as improve care practices.

D.Typically, the evaluation should occur within 1-4 hours depending on the facility's policy and the urgency of the situation.

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Correct Answer is D

Explanation

A. A client who has new-onset delirium: Delirium is characterized by acute confusion and changes in cognition, often due to underlying medical conditions. Assertiveness training may not be appropriate for someone experiencing delirium, as their cognitive impairment may interfere with their ability to participate effectively in the therapy session.

B. A client who is experiencing auditory hallucinations: Auditory hallucinations involve perceiving sounds or voices that are not actually present. Assertiveness training may not directly address the underlying cause of auditory hallucinations, which typically require other therapeutic approaches such as medication management and cognitive-behavioral therapy.

C. A client who is experiencing mania: Mania is a state of elevated mood, increased energy, and often impulsivity. While assertiveness training could potentially be beneficial for individuals with bipolar disorder during periods of stability, it may not be appropriate during acute manic episodes when the client's judgment and insight may be impaired.

D. A client who has somatic symptom disorder: Somatic symptom disorder involves experiencing distressing physical symptoms that are disproportionate to any identified medical condition. Assertiveness training could be helpful for individuals with somatic symptom disorder to effectively communicate their concerns with healthcare providers and advocate for appropriate care.

A. “I place my child in time-out for 15 minutes when they misbehave.” B. "I send my child to their room for the time-out period." C. “I make use of time-out after gang three warnings." D. “I use a kitchen timer to mark the end of the time-out period.”

Correct Answer is D

Explanation

A. “I place my child in time-out for 15 minutes when they misbehave.”: This statement indicates a clear understanding of time-out as a form of discipline. Time-out is typically implemented for a short duration, often recommended to be around one minute per year of the child's age (e.g., 3 minutes for a 3-year-old). Placing the child in time-out for 15 minutes aligns with this understanding.

B. "I send my child to their room for the time-out period.": Sending a child to their room as a time-out may not be as effective, as the child may have access to toys, books, or other distractions in their room. Time-out is more effective when the child is placed in a designated, neutral area with minimal stimulation.

C. “I make use of time-out after giving three warnings.": While giving warnings before implementing time-out can be part of a structured discipline approach, the number of warnings may vary depending on the situation and the child's behavior. There is no universally recommended number of warnings before using time-out.

D. “I use a kitchen timer to mark the end of the time-out period.”: Using a kitchen timer to mark the end of the time-out period is a practical strategy that helps ensure consistency and fairness in the duration of time-out. It indicates an understanding of the need to adhere to a specific time frame for time-out.Using a timer helps ensure that the time-out duration is consistent and allows the child to know when the consequence ends.

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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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