A nurse is developing a plan of care for a school-age child who has ADHD. Which of the following interventions should the nurse include in the plan?

A. Document the client's behavior hourly on a flow sheet: While documentation is important, it is more frequent than hourly. Clients in restraints should be observed and documented on more frequently, usually every 15 minutes to ensure safety and assess the client's condition.

B. Request a PRN client prescription for restraints from the provider: Restraints require a specific order from the provider, not a PRN (as needed) prescription. The order must be obtained initially and renewed per the facility's policy, typically every 24 hours.

C. Observe the client's behavior once every 15 minutes: Clients in restraints must be closely monitored for safety and well-being. The nurse should assess the client’s condition, including physical and emotional status, every 15 minutes.

D. Remove the restraint when the client calmly follows commands: Restraints should only be removed under appropriate conditions as assessed by the nurse, and with a provider’s order when necessary. The client's behavior alone does not determine the removal of restraints.

A. "We will help get you through this. You'll be fine.": While this statement may be meant to comfort, it dismisses the client's feelings and doesn't address the possibility of immediate harm or crisis. It’s important to validate the client’s emotions and assess for safety.

B. "What have you done to change your situation?": This response can come across as accusatory or judgmental, which may not be helpful in a crisis situation. It’s important to be supportive and nonjudgmental rather than questioning the client’s actions.

C. "Are you thinking about harming yourself?": The client's statement indicates feelings of hopelessness, which could signal suicidal ideation. Directly asking about self-harm or suicide helps assess the client's safety and provides an opportunity to intervene if necessary.

D. "You should remove yourself from this situation now.": While suggesting safety is important, this statement may feel too directive or overwhelming. The nurse should assess the client’s readiness for action and help them explore their options in a supportive way.