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?

Assess the client's need for toileting every 15 min.

Ask the provider to renew the prescription every 8 hr.

Have a staff member check on the client every 30 min.

Offer hydration and nutrition to the client every 2 hr.

Answer and Explanation

The Correct Answer is A

A.   The nurse should assess the client’s need for toileting regularly, as restricted movement can increase the risk of discomfort and physical harm. Monitoring this every 15 minutes is recommended for ensuring the client's basic needs are met.
B.   Physical restraint prescriptions should be renewed at intervals that are consistent with the facility’s
policies, but every 8 hours is typically too long. A more frequent reassessment should occur.
C.   Clients in restraints should be monitored more frequently than every 30 minutes to ensure their safety and well-being, especially in terms of physical comfort and circulation.
D.   Offering hydration and nutrition every 2 hours may not be necessary if the client is receiving fluids and food regularly, but they should be monitored more frequently for other immediate needs.

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Correct Answer is A

Explanation

A. Clients with paranoid personality disorder often have difficulty trusting others, so providing written information about their treatment plan allows them to review it at their own pace, which can help build trust.
B. Countertransference involves the nurse projecting their feelings onto the client, which is not appropriate for establishing a therapeutic relationship. The nurse should maintain objectivity and professionalism.
C. Splitting is more common in clients with borderline personality disorder, not paranoid personality disorder. Monitoring for defensive or suspicious behaviors is more relevant in paranoid personality disorder.
D. Isolation is not a beneficial intervention for clients with paranoid personality disorder. Social interactions may actually help the client develop trust over time if managed properly.

A. Discuss the provider's goals for the client's care. B. Request the provider prescribe a second antipsychotic medication to the client. C. Ask the client if the medication is causing adverse effects. D. Tell the client they will be admitted to an inpatient care facility if they do not take the medication.

Correct Answer is C

Explanation

A. Discussing the provider's goals might not address the client’s reasons for non-adherence and could be seen as dismissive.
B. Prescribing another medication without addressing the reasons for non-adherence may not solve the underlying problem.
C. Asking about adverse effects shows empathy and provides an opportunity to address concerns and encourage adherence.
D. Threatening hospitalization is not therapeutic and may make the client more resistant to taking the medication.

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