A charge nurse making rounds observes that an assistive personnel 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?
Review the chart for nonrestraint alternatives for agitation
Inform the unit manager of the incident
Speak with the AP about the incident
Remove the restraints from the client’s wrists
The Correct Answer is D
a. Review the chart for nonrestraint alternatives for agitation:
This action involves assessing the client's history, current condition, and any documented alternatives to restraints for managing agitation. While exploring nonrestraint interventions is important, addressing the immediate issue of inappropriate restraint use should take precedence.
b. Inform the unit manager:
Notifying the unit manager about the incident is important for escalating the situation and involving higher-level management in addressing the inappropriate use of restraints. However, before escalating, the immediate needs of the client should be addressed.
c. Speak with the AP about the incident:
Engaging in a conversation with the assistive personnel (AP) who applied the restraints allows for clarification of the situation, identification of any misunderstandings or training needs regarding restraint use, and immediate removal of the restraints if necessary. However, ensuring the client's safety should be the first priority.
d. Remove the restraints from the client’s wrist:
In situations where restraints are applied without a prescription or appropriate authorization, it is crucial to remove the restraints promptly to prevent potential harm to the client. However, it is essential to address the root cause of the inappropriate use of restraints and ensure that the client receives appropriate care and monitoring following restraint removal.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
a. Is the client’s family present so the AP can show them how to turn the client:
While involving the client's family in care can be beneficial for education and support, this assessment does not directly pertain to the AP's ability to provide care or the client's immediate needs.
b. Does the AP have time to change the client’s central IV-line dressing after turning her:
This assessment is relevant to the AP's workload and scheduling, but it does not directly address the client's care needs related to bathing and turning.
c. Has data been collected about specific client needs related to turning:
This assessment is crucial before delegating care. The nurse should ensure that relevant information about the client's condition, including any specific needs or considerations related to turning, has been gathered and communicated to the AP to provide appropriate care.
d. Has the AP checked the client’s pain level prior to turning her:
This assessment is essential to ensure the client's comfort and safety during care activities. Assessing the client's pain level before turning helps prevent exacerbation of pain and ensures that turning is performed with appropriate consideration for the client's comfort.
Correct Answer is D
Explanation
a. Compromising:
Compromising involves finding a middle ground or mutually acceptable solution where both parties give up something to reach an agreement. It requires each party to make concessions to meet halfway and resolve the conflict. This approach aims to achieve a quick resolution by accommodating the needs and concerns of both sides to some extent.
b. Collaborating:
Collaborating involves working together cooperatively to find a solution that satisfies the interests and concerns of all parties involved. It requires open communication, active listening, and joint problem-solving to achieve a consensus and reach a win-win outcome. This approach values mutual respect, trust, and cooperation among team members, emphasizing shared decision-making and collective ownership of the resolution.
c. Cooperating:
Cooperating involves willingly assisting or supporting others to achieve a common goal or resolve a conflict. It emphasizes teamwork, mutual support, and shared efforts to address challenges or differences constructively. This approach promotes harmony, unity, and a supportive environment where individuals work together toward shared objectives.
d. Competing:
Competing, also known as forcing or dominating, involves pursuing one's own interests or preferences at the expense of others' concerns or viewpoints. It prioritizes assertiveness and control, with the goal of achieving one's desired outcome without considering the needs or perspectives of others. This approach can lead to conflict escalation, resentment, and strained relationships, as it disregards collaboration and mutual understanding in favor of imposing one's will.
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