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. Asking the client's son to go to the waiting area allows the nurse to have a private conversation with the client, which is crucial in suspected cases of elder abuse to gather information without potential interference or intimidation.
B. Asking about injuries with the son present might hinder the client from disclosing information due to fear or pressure.
C. Treating and discharging the client without addressing the suspected elder abuse could potentially put the client in further danger.
D. Filing an incident report might be necessary but should follow an assessment and investigation of the situation.

A. Report the infection to the local health department. B. Apply an antiviral cream to lesions. C. Instruct the client to use condoms until the treatment is completed. D. Initiate contact precautions.

Correct Answer is A

Explanation

A. Reporting infections like chlamydia to the local health department is crucial for public health monitoring and contact tracing to prevent further spread of the infection.
B. Chlamydia is a bacterial infection, and antiviral creams are not effective against it.
C. While advising the client about preventive measures like condom use is important, reporting the infection is the priority for public health purposes.
D. Contact precautions are not necessary for chlamydia as it is primarily spread through sexual contact and not through casual contact or airborne transmission.

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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?

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