A nurse is collecting data from a client who has alcohol use disorder and is experiencing withdrawal. Which of the following manifestations should the nurse expect?

Choice A Reason:

Restraining the child's upper extremities is not recommended. It's important to allow the child to move freely during the seizure to prevent injury. Attempting to restrain their movements could result in harm to the child or the person attempting to restrain them.

Choice B Reason:

Turning the child onto their back is generally appropriate as long as you do it gently and without force. It helps ensure that the airway remains clear and allows any fluids to drain out of the mouth. However, you should not forcibly turn the child; instead, gently guide them if necessary.

Choice C Reason:

Placing a padded tongue blade or any object in the child's mouth is strongly discouraged during a seizure. Doing so can result in injury to the child's mouth, teeth, or jaw. It is a common misconception that someone might swallow their tongue during a seizure, but this rarely happens. It's essential to keep the child's airway clear but not to insert any objects into their mouth.

D. Placing a pillow under the child's head is appropriate to protect their head from injury, especially if they are on a hard surface. It can help cushion the head and reduce the risk of head trauma during the seizure.

Rationale:
A. Promoting trust: Interrupting the bath to ensure the client receives nourishment demonstrates the nurse’s attentiveness, responsiveness, and prioritization of the client’s well-being. This action fosters a therapeutic relationship and builds trust between the nurse and client.

B. Boundary crossing: Boundary crossing occurs when a nurse engages in actions that deviate from professional limits, potentially for personal or emotional reasons. In this case, providing food to meet a basic client need does not constitute a boundary violation.

C. Veracity: Veracity refers to the ethical principle of being truthful with clients. While honesty is important in nursing, providing a meal to the client addresses their immediate physiological need rather than demonstrating truthfulness.

D. Countertransference: Countertransference happens when a nurse projects personal feelings onto a client, which can interfere with care. The nurse’s action here is intentional and focused on meeting the client’s needs, not influenced by personal unresolved emotions.