A nurse is working with a client who becomes combative and threatens other clients and staff. Which of the following actions should the nurse take?

Choice A reason: Massaging a DVT risks dislodging the clot, causing embolism. In postpartum with anticoagulants, this is contraindicated to prevent lethal complications.

Choice B reason: Bed rest minimizes clot movement in DVT, aiding anticoagulation postpartum. It reduces embolism risk, a critical safety measure in this scenario.

Choice C reason: Ice may reduce swelling, but it’s not standard for DVT with anticoagulants. Elevation and rest are prioritized over cold therapy here.

Choice D reason: Aspirin isn’t used with anticoagulants like heparin; it increases bleeding risk. Postpartum DVT needs specific pain management, not this drug.

Choice A reason: Measuring seizure duration is critical for medical management, as prolonged seizures (over 5 minutes) may require emergency intervention like anticonvulsants. Timing helps assess severity and guides treatment, prioritizing safety and data collection over unnecessary restraint, aligning with evidence-based practice.

Choice B reason: Restraining arms and legs during a seizure risks injury like fractures or dislocations, as tonic-clonic movements are involuntary and forceful. Safety involves clearing the area, not restricting motion, since restraint opposes neurological protocols, increasing harm rather than protecting the client.

Choice C reason: Lowering side rails during a seizure increases fall risk, as tonic-clonic activity can propel the client off the bed. Keeping rails up, padded if possible, ensures safety by containing movement, contradicting this action’s utility, as evidence prioritizes preventing trauma.

Choice D reason: Inserting an oral airway during a seizure is dangerous; clenched jaws can break teeth or the device, risking aspiration. Airway management occurs post-seizure if needed, not during, as neurological guidelines emphasize protection without invasive actions causing injury.