A charge nurse making rounds observes that an assistive personnel (AP) has applied wrist restraints to a client who is agitated and does not have a prescription for restraints. Which of the following actions should the nurse take first?

Inform the unit manager of the incident.

Speak with the AP about the incident.

Remove the restraints from the client's wrists.

Review the chart for nonrestraint alternatives for agitation,

Answer and Explanation

The Correct Answer is C

A.   Informing the unit manager is essential but not the first immediate action when a client is improperly restrained.
B.   Speaking with the AP about the incident is important, but the priority is to ensure the client's safety and well-being.
C.   Removing the restraints from the client's wrists is the first action to address the
inappropriate application of restraints without a prescription to ensure the client's safety and prevent harm.
D.   Reviewing the chart for nonrestraint alternatives for agitation is important, but the priority is to address the immediate issue of the improperly applied restraints to the client.

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Correct Answer is A

Explanation

A. Battery involves unauthorized or harmful physical contact, which administering the injection without consent would constitute.
B. False imprisonment involves restricting a person's freedom of movement unlawfully, which doesn't apply in this scenario.
C. Assault involves the threat of unwanted or harmful contact.
D. Libel refers to written defamation or false statements that damage someone's reputation, which is not relevant in this situation involving administering medication.

A. Contact the case manager to discuss discharge options. B. Recommend the partner place the client in a long-term care facility. C. Request another family member assist the client's partner with care. D. Ask the provider to delay the client's discharge home for a few more days

Correct Answer is A

Explanation

A. Contacting the case manager is crucial to explore various discharge options and ensure the client's needs are met appropriately.
B. Recommending long-term care should be considered after exploring other options and assessing the client's specific needs.
C. Requesting assistance from another family member is a potential option but should be explored in conjunction with other solutions.
D. Delaying discharge might not address the partner's inability to provide care and doesn't explore alternative solutions.

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A charge nurse making rounds observes that an assistive personnel (AP) has applied wrist restraints to a client who is agitated and does not have a prescription for restraints. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is A

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