A nurse is performing a family assessment for a client who has recently developed paraplegia following a stroke. Which of the following actions should the nurse take first?

A. Only use restraints if the client becomes violent: Restraints should be used as a last resort when the client poses a danger to themselves or others. They are not meant for convenience or managing disorientation alone.

B. Use seclusion to manage the client's behavior: Seclusion is typically reserved for managing severe aggression or self-harm in psychiatric settings. It is not an appropriate first-line intervention for a disoriented client attempting to get out of bed.

C. Attempt the use of less restrictive methods before using restraints: The nurse should first implement interventions such as frequent monitoring, bed alarms, or sitter assistance. This approach prioritizes client safety while respecting autonomy and minimizing harm.

D. Use restraints for the minimum amount of time necessary: If restraints are applied, they must be removed as soon as it is safe to do so to prevent physical and psychological complications, adhering to best practice and regulatory guidelines.

E. Ensure the restraint limits the client's movement as little as possible: Proper application of restraints focuses on safety while allowing maximum mobility and comfort. Overly restrictive restraints can cause injury, skin breakdown, and additional stress.

A. Place a vibrating tuning fork on the top of the client's head: This describes the Weber test, which assesses lateralization of sound to determine conductive versus sensorineural hearing loss.

B. Move a vibrating tuning fork's prongs in front of the client's left or right ear canal: In the Rinne test, the nurse compares bone conduction and air conduction. After placing the fork on the mastoid bone, it is moved in front of the ear canal to test air conduction, which should normally be longer than bone conduction.

C. Activate a tuning fork and place the prongs on the client's occipital area: Placing the tuning fork on the occipital bone is not part of any standard hearing assessment test. It would not yield useful information about bone or air conduction.

D. Instruct the client to occlude one ear and repeat a softly spoken phrase by the nurse: This describes the whisper test, a screening tool for gross hearing acuity. It is not related to the Rinne test procedure.