A nurse notices that a client's health information is visible on an unattended computer screen at the nurses' station.
Which of the following actions should the nurse take first?

Choice A rationale

Suggesting long-term care placement may disregard the client’s autonomy and independence. Postoperative care often emphasizes rehabilitation and support, not institutionalization, unless medically necessary or preferred by the client. Autonomy is vital in discharge planning, aligning with patient-centered care principles.

Choice B rationale

Referral to social services connects the client with resources like home care or rehabilitation. Social workers can assess unmet needs and coordinate assistance, ensuring a safe discharge. Collaboration improves outcomes in individuals lacking support systems.

Choice C rationale

Ethics committees address dilemmas with moral implications, like end-of-life care. Discharge planning typically requires clinical and social assessment rather than moral adjudication. Engaging the ethics committee unnecessarily delays support.

Choice D rationale

Discharge timing is based on clinical readiness and does not hinge solely on the client’s social situation. Suggesting delay may not address unmet needs. Utilizing support resources is more constructive.

Choice A rationale

Applying wrist restraints immediately is an invasive intervention that may escalate the client’s agitation and anger. Restraints are used when absolutely necessary to prevent harm, and only after other de-escalation techniques have failed. Their use may breach the least restrictive intervention principle, which prioritizes non-invasive measures first.

Choice B rationale

Engaging the client in a repetitive activity acts as a distraction and can reduce agitation by refocusing their attention. This technique aligns with dementia care principles, emphasizing non-pharmacological interventions to manage behavioral disturbances. By promoting sensory engagement, it can help mitigate aggression effectively and respectfully.

Choice C rationale

Placing the client in a seclusion room can escalate feelings of confusion, isolation, and fear, worsening agitation. Seclusion should only be a last resort for safety reasons and not a first-line intervention in dementia care. It is contraindicated unless immediate harm is likely.

Choice D rationale

Administering haloperidol without first attempting non-pharmacological interventions disregards the principle of using medications judiciously. While haloperidol may calm agitation, side effects such as sedation or movement disorders make it inappropriate as a first-line option. This choice should follow other measures.