Exhibits

The primary nurse reviews the client's history and vital signs. Select the 3 priority assessment findings that require immediate follow up.

Rationale:

A. A family member expresses concern about their relative "picking" at the nasogastric (NG) tube: Family concern should be acknowledged, but restraint use must be based on clinical necessity. The nurse can first implement non-restrictive interventions before considering restraints.

B. A client is walking the halls at night rubbing his hands together: This behavior does not indicate harm to self or others or interference with medical devices. There is no justification for restraint, and doing so could violate patient rights and ethical standards.

C. A 16-year-old boy swung his fist at the nurse: This may call for emergency behavioral restraints rather than mitten restraints. If the behavior poses a threat of violence, other forms of crisis intervention or behavioral management should be pursued first.

D. A disoriented client removed the mesh-wrapped intravenous (IV) line for the second time: Mitten restraints may be considered when a client repeatedly removes critical lines or tubes, especially when cognitively impaired. This situation meets the clinical indication for discussing their use with the provider to prevent treatment disruption while ensuring safety.

Rationale:
A. Any antianxiety medications: Antianxiety medications are not contraindicated with ophthalmic timolol. Unless they directly impact heart rate or blood pressure significantly, they are generally safe to continue in clients with glaucoma using topical beta blockers.

B. Over-the-counter oral antipyretics: Oral antipyretics like acetaminophen are not known to interact adversely with timolol. These medications can be used safely unless otherwise contraindicated for specific patient conditions like liver disease.

C. Nonsteroidal antiinflammatory drugs: NSAIDs such as ibuprofen, when used long-term with beta blockers like timolol or carvedilol, may blunt the antihypertensive effect and increase renal risk, especially in clients on diuretics like spironolactone. This triple combination increases the chance of nephrotoxicity.

D. Other beta-adrenergic blocker agents: Using timolol with systemic beta blockers like carvedilol increases the risk of bradycardia, hypotension, and heart block. Though timolol is topical, systemic absorption can still occur, requiring caution when combining with other beta-blockers.

E. Oral and subcutaneous anticoagulants: There is no direct contraindication between timolol and anticoagulants. Unless the client has bleeding risks associated with other therapies or conditions, concurrent use is generally acceptable.