A charge nurse making rounds observes that 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
Speak with the AP about the incident
Remove the restraints from the client’s wrist
The Correct Answer is D
a. Review the chart for nonrestraint alternatives for agitation: While reviewing alternatives is important, the immediate concern is ensuring the safety and well-being of the client by removing the restraints.
b. Inform the unit manager: While it's important to inform the unit manager, the first action should be to address the immediate safety issue by removing the restraints.
c. Speak with the AP about the incident: While it's important to discuss the incident with the assistive personnel, the first priority is to remove the restraints to prevent harm to the client.
d. Remove the restraints from the client’s wrist: This is the correct action to take first to ensure the client's safety and prevent further harm. Afterward, the nurse can address the situation with the assistive personnel and review alternatives for managing the client's agitation.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
. Inform the client that she cannot leave without a discharge prescription from the provider
Rationale:
a. Offering a sedative may not address the client's concerns and is not an appropriate response to the situation.
b.Inform the client that she cannot leave without a discharge prescription from the provider. Clients have the right to leave against medical advice; informing them otherwise infringes on their rights.
C Have the client sign the Against Medical Advice form. This action respects the client's autonomy while ensuring documentation of her decision to leave against medical advice, which protects both the client and healthcare facility legally.
d. Assigning a security officer to the client's room may escalate the situation unnecessarily. The focus should be on communication and education.
Correct Answer is C
Explanation
a. Assault: Assault is the threat of harm to another individual, such as threatening to administer the injection against the client's will. However, since the nurse actually administers the injection, it does not constitute assault.
b. Libel: Libel refers to a false statement that is written and published, which is not relevant in this scenario.
c. Battery: Battery involves the unauthorized or harmful physical contact with another individual, such as administering the injection without the client's consent.
d. False imprisonment: False imprisonment occurs when an individual is unlawfully restrained or confined. While the client's movement may be restricted by administering the injection, the primary issue here is the unauthorized physical contact, making battery the more appropriate choice.
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