A nurse is caring for a client who is incontinent of urine. Which of the following actions should the nurse take?

ACE inhibitors are commonly prescribed antihypertensive medications that reduce blood pressure by blocking the conversion of angiotensin I to angiotensin II, leading to vasodilation and decreased peripheral resistance. A common early adverse effect is orthostatic hypotension, which can cause dizziness or lightheadedness when standing due to sudden drops in blood pressure. Patient education focuses on safety measures, gradual position changes, and monitoring for side effects. Proper teaching helps prevent falls and improves medication adherence.

Rationale:
A. Sitting back down when lightheadedness occurs is appropriate because it helps restore cerebral perfusion and reduces the risk of falls. This is a key safety strategy for managing orthostatic hypotension associated with ACE inhibitor therapy. Clients should also be taught to rise slowly from sitting or lying positions to minimize symptoms.

B. Restricting fluid intake is incorrect because dehydration can worsen orthostatic hypotension by reducing circulating blood volume. Adequate hydration helps maintain blood pressure stability and reduces dizziness. Fluid restriction would therefore increase the risk of adverse effects.

C. Taking a daily potassium supplement is incorrect because ACE inhibitors can increase potassium levels, leading to hyperkalemia. Supplementation without medical indication may result in dangerous cardiac dysrhythmias. Potassium levels should be monitored rather than routinely supplemented.

D. Discontinuing the medication if symptoms occur again is inappropriate because orthostatic hypotension is a common early side effect that often improves with time and proper management. Abrupt discontinuation can lead to uncontrolled hypertension and increased cardiovascular risk. The provider should be notified if symptoms persist or worsen, rather than stopping the medication independently.

Use of physical restraints in a mental health setting requires strict adherence to safety protocols to protect client dignity, prevent injury, and ensure ongoing assessment of neurovascular status and behavioral response. Wrist restraints are used only when less restrictive interventions have failed and when there is imminent risk of harm to self or others. Continuous monitoring and frequent documentation are essential to evaluate circulation, skin integrity, and the ongoing need for restraints. Nursing care must also ensure proper application and legal compliance.

Rationale:
A. Securing restraints to the side rail is unsafe and contraindicated because side rails are movable and may cause entanglement or injury if the rail is lowered or adjusted. Restraints should be attached to a part of the bed frame that is immovable to ensure stability and prevent accidental tightening or loosening. This reduces the risk of client harm during movement or bed adjustments.

B. A new prescription for restraints is required within a specific timeframe depending on the client’s age and institutional policy, but 48 hours is incorrect. For adults, restraint prescriptions typically require renewal within 4 hours for violent behavior and 24 hours for non-violent situations. This ensures ongoing justification for restraint use and prevents unnecessary prolonged immobilization.

C. Tying restraints with a tight knot is incorrect because it can impair circulation and increase risk of neurovascular injury. Restraints should be secured with quick-release knots to allow rapid removal in emergencies. Proper technique ensures both safety and the ability to quickly release restraints if complications arise.

D. Documenting observations every 15 minutes is essential to ensure continuous monitoring of the client’s physical and psychological status while restrained. This includes assessment of circulation, skin integrity, range of motion, hydration, and behavior. Frequent documentation ensures that restraints remain justified, safe, and are removed as soon as clinically appropriate.