A behavioral health unit nurse is caring for a newly admitted client.

Exhibits

Complete the following sentence by using the lists of options:

The client demonstrates risk for

dropdown

due to

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.

Choice A reason:
Having a staff member check on the client every 30 minutes is important for ensuring the client's safety and well-being. However, best practices suggest that continuous visual monitoring or checks at least every 15 minutes is generally recommended. This frequent monitoring allows for prompt identification and response to any distress or needs the client may have.

Choice B reason:
Assessing the client's need for toileting every 15 minutes may be excessive and could potentially cause additional distress or discomfort. The standard practice is to assess for toileting needs less frequently, typically every 2 hours, unless there is a specific indication that more frequent checks are necessary.

Choice C reason:
Asking the provider to renew the prescription for restraints every 8 hours is not aligned with standard guidelines. Restraint orders must be reviewed and renewed according to facility protocols, which usually require renewal every 24 hours. This ensures that the use of restraints is continually justified and that the client's condition is regularly reassessed.

Choice D reason:
Offering hydration and nutrition to the client every 2 hours is a critical aspect of care for a client in restraints. It is essential to meet the client's basic needs and to prevent dehydration and malnutrition. Additionally, providing hydration and nutrition at regular intervals aligns with the guidelines for monitoring and assessing clients in restraints.

Choice A reason:
Telling the client that they will eventually get used to people talking at night is not a supportive or effective response. It dismisses the client's current discomfort and does not address the immediate issue of noise disrupting their sleep. Clients in inpatient treatment for eating disorders often have heightened sensitivity to their environment, and dismissing their concerns can increase stress and anxiety.

Choice B reason:
Recommending that the client try to sleep during the day when it is quieter is not practical. It disrupts the client's natural circadian rhythm and can lead to further sleep disturbances. Encouraging a regular sleep schedule at night is more beneficial for overall health and recovery.

Choice C reason:
Keeping conversations and activities to a minimum during the nighttime is the most appropriate action. This approach directly addresses the client's concern about noise and helps create a quieter, more restful environment. Reducing noise levels at night can significantly improve sleep quality for clients in inpatient settings.

Choice D reason:
Turning on the client's television at night to cover up environmental noises is not advisable. While it might mask some noise, it can also introduce new disturbances and prevent the client from achieving deep, restorative sleep. The light and sound from the television can interfere with the body's natural sleep processes.