A nurse is caring for a client who is confused and uncooperative. The client hit the nurse when they attempted to give them their medication. The nurse asks the charge nurse if she can apply restraints on the client. The charge nurse should explain to the nurse this action is a violation of the client’s rights and is an example of which tort?

Choice A Reason:

Providing a bed bath is a task that can be delegated to unlicensed assistive personnel (UAP). This task is routine and does not require clinical judgment or advanced nursing skills. UAPs are trained to perform basic care activities such as bathing, which helps maintain the client’s hygiene and comfort.

Choice B Reason:

Assisting in toileting is another task that can be delegated to UAPs. This task involves helping clients with their toileting needs, which is within the scope of practice for UAPs. It does not require the clinical judgment or assessment skills that are reserved for licensed nurses.

Choice C Reason:

Evaluating the effectiveness of a treatment is a task that cannot be delegated to UAPs. This task requires clinical judgment and the ability to assess the client’s response to treatment, which are responsibilities of licensed nurses. Only licensed nurses have the training and expertise to evaluate treatment outcomes and make necessary adjustments.

Choice D Reason:

Assessment of a stoma is a task that cannot be delegated to UAPs. Assessing a stoma involves evaluating its appearance, function, and any signs of complications, which requires clinical judgment and expertise. This task is within the scope of practice for licensed nurses, who are trained to perform comprehensive assessments.

Choice E Reason:

Discharge teaching is a task that cannot be delegated to UAPs. Discharge teaching involves providing clients with important information about their care after leaving the healthcare facility, including medication instructions, follow-up appointments, and lifestyle modifications. This task requires clinical knowledge and the ability to educate clients effectively, which are responsibilities of licensed nurses.

Choice A Reason:

The client has full range of motion in her wrist does not necessarily indicate a need to loosen the restraints. Full range of motion suggests that the restraints are not too tight and are allowing for some movement. However, it is important to regularly assess the client’s circulation, skin integrity, and comfort to ensure the restraints are not causing harm.

Choice B Reason:

The client is attempting to remove the restraint is a common behavior in clients who are restrained, especially if they are confused or agitated. While this behavior warrants close monitoring and possibly re-evaluating the need for restraints, it does not necessarily indicate that the restraints need to be loosened. The nurse should assess the client’s overall condition and consider alternative methods to ensure safety.

Choice C Reason:

The client has cyanotic digits is a critical finding that indicates impaired circulation. Cyanosis, or a bluish discoloration of the skin, occurs when there is a lack of oxygen in the blood. This can be a sign that the restraints are too tight and are restricting blood flow to the extremities. In this case, the nurse should immediately loosen the restraints to restore proper circulation and prevent further complications.

Choice D Reason:

The client denies discomfort is a positive finding, indicating that the client is not experiencing pain or distress from the restraints. However, the absence of discomfort does not rule out other potential issues such as impaired circulation or skin breakdown. Regular assessments are necessary to ensure the restraints are being used safely and effectively.