A nurse is collecting data from a client who is taking amitriptyline. Which of the following findings should the nurse report to the provider as an adverse effect of the medication?

Choice A reason: Using a quick-release tie for restraints ensures that the nurse can quickly and easily release the client in case of an emergency. Quick-release ties are designed to provide safety and convenience, allowing healthcare providers to promptly respond to the client's needs without compromising safety. This method reduces the risk of injury to both the client and the healthcare team.

Choice B reason: Restraint prescriptions typically need to be renewed more frequently than every 48 hours, often within 24 hours. The exact duration depends on the facility's policy and regulatory guidelines. Regular assessment of the need for restraints and timely renewal of the prescription ensure that restraints are used appropriately and only as long as necessary.

Choice C reason: Attaching restraints to the side rail of the client's bed is unsafe and inappropriate. Restraints should be attached to a non-movable part of the bed frame to prevent the client from injuring themselves if the side rail is moved. Securing restraints to a stable part of the bed ensures better control and reduces the risk of harm.

Choice D reason: While maintaining some space between the restraint and the client's skin is important to prevent circulation issues, the guideline typically suggests maintaining two fingers' breadth between the restraint and the client's skin, not one. This ensures adequate circulation and reduces the risk of injury or skin breakdown.

Choice A reason: If a nurse suspects child abuse, they are legally required to report it to the appropriate authorities. Informing the parents that the findings must be reported is necessary to comply with mandatory reporting laws. This step ensures that the child receives the necessary protection and that the situation is investigated further by child protective services or law enforcement.

Choice B reason: Completing an incident report for risk management is an internal process used by healthcare facilities to document incidents that occur within the facility. While it is important to document the findings, this action alone does not fulfill the nurse's legal obligation to report suspected abuse to the authorities.

Choice C reason: Interviewing the child about the suspected abuse with a parent present may not be appropriate, especially if there is a possibility that the parent is the abuser. The presence of the parent could influence the child's responses and prevent them from speaking freely about the abuse. It is crucial to conduct the interview in a safe and supportive environment, often with a child protection professional or a social worker.

Choice D reason: Avoiding asking the child what caused the injury is not recommended in cases of suspected abuse. It is important for the nurse to gather as much information as possible about the cause of the injury. However, the nurse should approach the questioning in a sensitive and non-leading manner to avoid further traumatizing the child.