A nurse is caring for a client who was placed in four-point restraints by the nursing staff following an episode of violent behavior. Which of the following actions should the nurse take?

Keep staff interactions with the client to a minimum.

Provide range-of-motion exercises to all extremities every 2 hr.

Request the provider renew the prescription in 24 hr.

Document the client's behavior in the medical record every 1 hr.

Answer and Explanation

The Correct Answer is C

A.   Keeping staff interactions to a minimum may not be beneficial as the client might require regular monitoring and interaction to assess their condition and needs.
B.   When a client is restrained, it's crucial to prevent complications such as muscle stiffness and joint contractures. Range-of-motion exercises help maintain circulation, prevent discomfort, and preserve joint mobility. However, this is not the most important action.
C.   Restraints should only be used when absolutely necessary and prescribed by a provider. In many jurisdictions and healthcare facilities, the use of restraints requires a specific order that must be renewed periodically (often every 24 hours). This practice ensures that the need for restraints is continually reassessed and that they are not used longer than necessary.
D.   Accurate and frequent documentation is essential when a client is restrained. Documentation should include the client's behavior, physical assessments, interventions provided (such as medication administration or hygiene care), and responses to interventions. However, this is not the most important action.

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Correct Answer is B

Explanation

A. Cognitive behavioral therapy (CBT) is a commonly used psychotherapy approach for bipolar disorder. Attending a CBT class typically does not require specific informed consent beyond the general consent for treatment, as it involves non-invasive, non-experimental therapeutic techniques aimed at improving coping skills and managing symptoms. In most cases, attending therapy sessions like CBT is considered part of routine care for mental health conditions.
B. Experimental medications involve drugs or treatments that are not yet approved by regulatory agencies (such as the FDA in the United States) for general use. For a client to participate in a clinical trial or receive an experimental medication, they must provide explicit informed consent after being informed about the potential risks, benefits, and uncertainties associated with the treatment. This process ensures that the client understands they are participating in research and not receiving standard care.
C. Participating in a group exercise program is generally considered a routine therapeutic intervention aimed at promoting physical health and well-being. While informed consent is important for all interventions, including exercise programs, it typically involves providing general information about the program's goals, activities, and any potential risks. Clients are not consenting to experimental treatments or procedures that go beyond standard exercise protocols.

D. Light therapy, also known as phototherapy, is a treatment often used for seasonal affective disorder (SAD) and other mood disorders. It involves exposure to specific wavelengths of light to regulate circadian rhythms and improve mood. While light therapy is a specialized treatment, it is a standard intervention for mood disorders and does not typically require separate informed consent beyond what is provided for standard medical treatments.

A. Timeout B. Restraint C. Diversion D. Therapeutic hold

Correct Answer is A

Explanation

A. This technique involves allowing the client to remove themselves from the situation causing agitation temporarily. It is a de-escalation technique where the client can regain composure and reduce agitation by being alone or in a quieter environment. The nurse ensures the environment is safe and monitors the client during this time.
B. Restraint involves physically restricting the client's movement to prevent harm to themselves or others when they are in a state of extreme agitation and are at risk of causing harm. It is used as a last resort and typically requires a healthcare provider's order due to the potential risks and ethical considerations.
C. Diversion involves redirecting the client's attention away from the source of agitation to something else, such as a calming activity or a change of topic. It can help shift the client's focus and reduce escalating emotions.
D. Also known as a therapeutic restraint hold, this technique is used to safely manage a client who is agitated and may become physically aggressive. It involves trained staff using specific holds to restrain the client in a way that prevents harm while allowing for therapeutic communication.

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A nurse is caring for a client who was placed in four-point restraints by the nursing staff following an episode of violent behavior. Which of the following actions should the nurse take?

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