A nurse is caring for an adult client who has been placed in physical restraints due to aggressive behavior. Which of the following actions should the nurse take?
Have a staff member check on the client every 30 minutes.
Assess the client's need for toileting every 15 minutes.
Ask the provider to renew the prescription every 8 hours.
Offer hydration and nutrition to the client every 2 hours.
The Correct Answer is D
Choice A reason:
Having a staff member check on the client every 30 minutes is important for ensuring the client's safety and well-being. However, best practices suggest that continuous visual monitoring or checks at least every 15 minutes is generally recommended. This frequent monitoring allows for prompt identification and response to any distress or needs the client may have.
Choice B reason:
Assessing the client's need for toileting every 15 minutes may be excessive and could potentially cause additional distress or discomfort. The standard practice is to assess for toileting needs less frequently, typically every 2 hours, unless there is a specific indication that more frequent checks are necessary.
Choice C reason:
Asking the provider to renew the prescription for restraints every 8 hours is not aligned with standard guidelines. Restraint orders must be reviewed and renewed according to facility protocols, which usually require renewal every 24 hours. This ensures that the use of restraints is continually justified and that the client's condition is regularly reassessed.
Choice D reason:
Offering hydration and nutrition to the client every 2 hours is a critical aspect of care for a client in restraints. It is essential to meet the client's basic needs and to prevent dehydration and malnutrition. Additionally, providing hydration and nutrition at regular intervals aligns with the guidelines for monitoring and assessing clients in restraints.
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Related Questions
Correct Answer is C
Explanation
Choice A reason:
A client with anorexia nervosa expressing a fear of gaining weight does require careful monitoring and intervention, but this does not typically pose an immediate risk to their safety. The treatment plan should focus on addressing the eating disorder and any associated psychological issues, but it may not necessitate an urgent change in the plan of care regarding safety concerns.
Choice B reason:
While a client with schizophrenia exhibiting tangential associations in speech indicates a need for ongoing psychiatric care, it does not inherently suggest an immediate risk to safety that would require an urgent update to the care plan. These speech patterns are a symptom of schizophrenia and should be addressed through appropriate therapeutic and medication management strategies.
Choice C reason:
A client with bipolar disorder exhibiting poor impulse control presents an immediate safety concern. Poor impulse control can lead to risky behaviors, self-harm, or harm to others. This situation requires an urgent update to the care plan to include safety measures such as close supervision, environmental modifications, and possibly medication adjustments to manage impulsivity.
Choice D reason:
A client with Alzheimer's disease having difficulty remembering the names of family members is experiencing a symptom of their condition. While this is distressing and requires a compassionate approach to care, it does not typically pose an immediate safety risk that would necessitate an urgent update to the care plan.
Correct Answer is C
Explanation
Choice A reason:
While the client's anger towards the provider is a valid emotional response and needs to be addressed, it is not the immediate priority. Anger is a common stage in the grieving process, and the nurse should acknowledge the client's feelings and provide support, but it does not pose an immediate risk to the client's physical health.
Choice B reason:
Feelings of guilt are also part of the normal grieving process. The nurse should provide a supportive environment for the client to express these feelings and work through them. However, this emotional concern, while important, is not as urgent as the client's physical health needs.
Choice C reason:
The client's inability to eat more than once a day is the most immediate concern because it can lead to nutritional deficiencies and affect overall health. This issue requires prompt intervention to ensure the client's physical well-being. The nurse should assess the reasons for the client's poor appetite and collaborate with the healthcare team to address this issue, potentially involving a dietitian and providing emotional support.
Choice D reason:
Recalling negative experiences during the marriage indicates that the client is processing past events, which is a part of the grieving process. It is important for the nurse to listen and provide support. However, this is not the immediate priority compared to the client's nutritional intake and physical health.
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