A nurse is contributing to the plan of care for a client who is experiencing a herpes simplex outbreak. Which of the following interventions should the nurse recommend?

A.Restraints should be released more frequently, typically every 2 hours, to assess circulation, skin integrity, and range of motion, and to provide an opportunity for toileting and other needs.

B.It is essential to document the specific behaviors that led to the use of restraints, as this provides a clear rationale for why the restraints were necessary. This documentation is important for legal and clinical reasons and helps ensure that restraints are used appropriately and only when absolutely necessary.

C.Clients are not required to provide written consent for the use of restraints, especially in situations where restraints are necessary to protect the client or others from immediate harm. However, the nurse must follow the facility's protocol, which usually involves obtaining a physician's order and documenting the justification for the restraint use.

D.The nurse should check the client's status more frequently, typically every 15 minutes, to ensure the client's safety and well-being while in restraints.

Incorrect Options

• Osteoporosis: This condition is primarily characterized by bone density loss and an increased risk of fractures. It would not be indicated by bilateral wrist and shoulder stiffness. Instead, osteoporosis symptoms include bone density loss and potentially fractures.
• Hypertension: Hypertension involves consistently high blood pressure. Bilateral wrist and shoulder stiffness are not typical symptoms of hypertension. The primary indicator for hypertension is elevated blood pressure.
• Diabetes Mellitus: This metabolic disorder is characterized by high blood glucose levels. Symptoms related to diabetes include elevated blood glucose levels, not joint stiffness.
• Chronic Obstructive Pulmonary Disease (COPD): COPD is a respiratory condition marked by shortness of breath, chronic cough, and other respiratory symptoms. It would not be indicated by joint stiffness but rather by respiratory difficulties such as shortness of breath.

In contrast, rheumatoid arthritis is an autoimmune disease that primarily affects the joints, leading to symptoms such as bilateral wrist and shoulder stiffness. Therefore, the correct answer is "rheumatoid arthritis" and "bilateral wrist and shoulder stiffness," while the incorrect options provided do not align with the symptoms of rheumatoid arthritis.