A nurse is caring for a client who repeatedly refuses meals.

The nurse overhears an assistive personnel (AP) telling the client, “If you don’t eat, I’ll put restraints on your wrists and feed you.” The nurse should intervene and explain to the AP that this statement constitutes which of the following torts?

Choice A reason:

Explaining the procedure to the client before verifying informed consent is not an appropriate action: While it is essential to explain the procedure to the client and ensure they have a clear understanding of what they are consenting to, this step typically occurs before the informed consent form is presented. The purpose of the informed consent form is to document that the client has received adequate information and has given their consent voluntarily

Choice B reason:

Confirming the client's signature is authentic is the correct action. Verifying the record of informed consent for a client scheduled for surgery involves several important steps. Of these, the nurse's primary responsibility is to ensure that the client's signature on the informed consent form is authentic. This means ensuring that the client themselves or their authorized representative has signed the form willingly and without coercion.

Choice C reason:

Providing information on the informed consent form about the benefits of the surgery is not an appropriate action: The informed consent form typically contains information about the procedure, its risks, possible complications, and alternatives, but it is not the nurse's responsibility to provide this information. The healthcare provider or surgeon is responsible for explaining the details of the surgery to the client before obtaining their consent.

Choice D reason:

Informing the client about the condition that requires treatment is not an appropriate action: The responsibility of informing the client about their medical condition, the need for treatment, and the available options lies with the healthcare provider or surgeon, not the nurse. The nurse may assist in providing information or answering questions, but the primary responsibility for discussing the medical condition lies with the provider.

Tell the client, “You seem to be very upset.”.

This is an example of a therapeutic communication technique that validates the client’s feelings and encourages them to express their emotions verbally rather than physically. It also shows empathy and respect for the client’s perspective.

Choice A is wrong because engaging the panic alarm is not the first action to take when interacting with an agitated client.

The nurse should first try to calm the client down by using verbal and nonverbal communication skills, such as maintaining eye contact, speaking in a calm and clear voice, and avoiding sudden movements or gestures.

Engaging the panic alarm should be done only if the client becomes violent or poses a threat to themselves or others.

Choice B is wrong because using a face shield with a mask when providing care to the client is not relevant to the situation.

This is a personal protective equipment (PPE) that is used to prevent exposure to infectious agents or body fluids, not to manage agitation.

Using a face shield with a mask may also increase the client’s anxiety or paranoia, as they may perceive it as a sign of hostility or fear.

Choice D is wrong because initiating seclusion protocol is not appropriate for a client who is agitated, pacing, and speaking loudly.

Seclusion is a restrictive intervention that involves isolating the client in a locked room to prevent harm to themselves or others.

It should be used only as a last resort when less restrictive measures have failed or are contraindicated, and only with a provider’s order and close monitoring.

Secluding an agitated client may escalate their behavior and violate their rights.

Normal ranges for agitation are not applicable, as agitation is not a quantifiable parameter.

However, some tools that can be used to assess agitation include the Richmond AgitationSedation Scale (RASS), which ranges from -5 (unarousable) to +4 (combative), and the Agitated Behavior Scale (ABS), which ranges from 14 (no agitation) to 56 (severe agitation).