A nurse is caring for a client who was placed in four-point restraints by the nursing staff following an episode of violent behavior.
Which of the following actions should the nurse take?.
Document the client's behavior in the medical record every 1 hr
Provide range-of-motion exercises to all extremities every 2 hr.
Request the provider renew the prescription in 24 hr.
Keep staff interactions with the client to a minimum.
The Correct Answer is B
Choice A rationale:
Documenting the client’s behavior every hour is not necessary. The nurse should monitor and document the client’s condition, but this does not need to be done every hour.
Choice B rationale:
Providing range-of-motion exercises to all extremities every 2 hours is important when a client is in restraints. This helps to prevent muscle stiffness and maintain circulation.
Choice C rationale:
The provider does not need to renew the prescription every 24 hours. The use of restraints should be reassessed regularly, but a new prescription is not required unless the restraints are removed and then need to be reapplied.
Choice D rationale:
Keeping staff interactions with the client to a minimum is not recommended. The client should be monitored closely and regular interaction can help to calm the client and reduce the need for restraints.
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Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Reinforcing teaching on the client’s use of coping skills is important, but it’s not the first action the nurse should take. The nurse must first ensure the client’s safety.
Choice B rationale:
Encouraging the client to use personal support systems is beneficial, but it’s not the first action. Safety is the priority.
Choice C rationale:
Assisting with a client referral for social services can be helpful, but it’s not the first action. The nurse must first assess for immediate safety risks.
Choice D rationale:
Identifying if the client has thoughts of self-harm is the first action the nurse should take. In a crisis situation, the client’s safety is the priority.
Correct Answer is B
Explanation
Choice A rationale:
It’s not appropriate to pressure the client into seeing visitors.
Choice B rationale:
It’s important to respect the client’s wishes and communicate them to the sibling.
Choice C rationale:
This could potentially cause distress for the client.
Choice D rationale:
While it might be helpful to involve the provider, the immediate issue can be addressed by the nurse.
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