A nurse on a mental health unit placed a client in mechanical restraints after the client assaulted another client. Which of the following actions should the nurse take?

Obtain a prescription for restraints on an as-needed basis.

Have the provider assess the client within 1 hr after applying the restraints.

Request that the provider renew the prescription for restraints every 8 hr.

Evaluate the client hourly while the restraints are applied.

Answer and Explanation

The Correct Answer is B

A. Obtain a prescription for restraints on an as-needed basis:
Restraints should never be used on an as-needed basis without a specific, individualized order from a healthcare provider. Restraints are a significant intervention that should only be used when necessary, and they require a clear prescription outlining the duration, reason, and method of application.

B. Have the provider assess the client within 1 hour after applying the restraints:
This option is the correct choice. It is crucial to involve the healthcare provider promptly after restraints are applied. The provider needs to assess the patient's physical and mental status, and the appropriateness of the restraints, and consider alternatives or modifications to the intervention. Regular assessments ensure the patient's safety and well-being while addressing the initial reason for applying restraints.

C. Request that the provider renew the prescription for restraints every 8 hours:
Restraining a patient every 8 hours without ongoing assessment and a clear clinical rationale is inappropriate and goes against best practices. Restraints should only be used when absolutely necessary and should be reevaluated frequently. Requesting a renewal on a fixed schedule without considering the patient's changing condition is not a safe or ethical approach.

D. Evaluate the client hourly while the restraints are applied:
While regular monitoring of a patient in restraints is essential, evaluating the patient every hour might not be sufficient, especially in the early stages after the application of restraints. The patient should be continuously monitored, with assessments conducted more frequently, especially immediately after applying the restraints, to ensure their safety and well-being.

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Correct Answer is B

Explanation

A. Seat the client at a dining table with six or more residents:
People with Alzheimer's disease often experience sensory overload in crowded and noisy environments. Large dining tables with multiple residents can be overwhelming for someone with Alzheimer's, leading to increased confusion and discomfort. It's more beneficial to seat them in a smaller, quieter setting to reduce stress and promote a more relaxed dining experience.

B. Use symbols to assist the client in locating rooms:
Individuals with Alzheimer's disease frequently have difficulties with memory and orientation. Using symbols or visual cues can aid them in understanding and remembering locations, reducing confusion and promoting independent movement within the facility or home.

C. Provide the client with several choices for meal selection:
While offering choices is generally a good practice, individuals with Alzheimer's disease may find it challenging to process too many options. Providing limited, clear choices can help prevent decision-making difficulties and reduce frustration. Too many choices can overwhelm them, leading to indecision and potential agitation.

D. Give complete directions before starting client care:
Providing complete and lengthy directions can overwhelm individuals with Alzheimer's disease. They may have difficulty processing complex instructions due to cognitive impairment. It's more effective to give simple, step-by-step directions and provide assistance as needed. Additionally, using gentle reminders and cues can support their understanding and cooperation without overwhelming them with too much information at once.

A. Reassure staff members that the debriefing is confidential. B. Have staff members discuss their involvement in the event. C. Ask staff members to describe their most traumatic memories of the event. D. Provide stress-management exercises to the staff members.

Correct Answer is A

Explanation

A. Reassure staff members that the debriefing is confidential:
Explanation: This step is crucial in establishing trust among the participants. Reassuring confidentiality encourages individuals to express their feelings and experiences openly. It helps create a safe environment where people can share their emotions without fear of judgment or repercussions.

B. Have staff members discuss their involvement in the event:
Explanation: After establishing confidentiality, it might be appropriate to encourage participants to discuss their involvement in the event. This allows individuals to share their perspectives and experiences, helping others understand the situation from different angles. Sharing experiences can provide insights into how different people were affected and how they coped.

C. Ask staff members to describe their most traumatic memories of the event:
Explanation: While it might be a natural inclination to immediately delve into the most traumatic memories, it's generally not the first step in a critical incident stress debriefing. Encouraging participants to share their most traumatic memories right away could be overwhelming and retraumatizing. The process usually begins with establishing trust and then progresses to discussing individual experiences, gradually leading to more specific and potentially distressing details.

D. Provide stress-management exercises to the staff members:
Explanation: Stress-management exercises are valuable and often an essential part of the debriefing process. However, introducing stress-management techniques usually comes after participants have had the opportunity to express their feelings and experiences. These exercises can include relaxation techniques, breathing exercises, or mindfulness practices, which help individuals manage their stress and anxiety effectively.

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