A client on the inpatient psychiatric unit is scheduled for discharge tomorrow. Which of the following statements would indicate that the client is ready for discharge?

Choice A Reason:

The statement “Documentation of the event will include interventions attempted prior to initiating restraints” is correct. Proper documentation is crucial when restraints are used. This includes detailing the client’s behavior that necessitated the restraint, the interventions attempted before applying the restraint, the type of restraint used, and the time it was applied. This documentation ensures transparency and accountability, and it helps in evaluating the necessity and appropriateness of the restraint use.

Choice B Reason:

The statement “The physician must be present at the time of the restraint episode” is incorrect. While a physician’s order is required for the use of restraints, the physician does not need to be physically present at the time of the restraint episode. However, the physician must evaluate the client within a specified time frame after the restraint is applied, typically within one hour. This ensures that the restraint is medically justified and that the client’s condition is appropriately monitored.

Choice C Reason:

The statement “The client will be turned every 2 hours” is correct. Clients in restraints must be regularly repositioned to prevent complications such as pressure ulcers and to ensure their comfort. Turning the client every 2 hours is a standard practice to maintain skin integrity and promote circulation. This intervention is part of the comprehensive care plan for clients in restraints.

Choice D Reason:

The statement “The client will need to be monitored every one-half hour” is correct. Frequent monitoring of clients in restraints is essential to ensure their safety and well-being. This includes checking for signs of distress, ensuring that the restraints are not causing harm, and assessing the client’s vital signs5. Monitoring every 30 minutes helps in promptly addressing any issues that may arise and ensures that the restraints are used safely and effectively.

Choice A Reason:

Increase external stimuli.

Increasing external stimuli is not appropriate during a panic attack. Panic attacks are characterized by intense fear and anxiety, often accompanied by physical symptoms such as rapid heartbeat, sweating, and shortness of breath. Increasing external stimuli can exacerbate these symptoms and heighten the client’s distress. The goal during a panic attack is to reduce stimuli and create a calming environment to help the client regain control.

Choice B Reason:

Stay with the client and speak to them in a calm manner.

This is the correct response. Staying with the client and speaking to them in a calm manner provides reassurance and helps to ground them during the panic attack. The presence of a calm and supportive nurse can help reduce the client’s anxiety and provide a sense of safety. This approach aligns with therapeutic communication techniques and is effective in managing acute anxiety episodes.

Choice C Reason:

Allow the client to have their requested space.

While it is important to respect a client’s need for space, leaving them alone during a panic attack may not be the best approach. Clients experiencing panic attacks may feel overwhelmed and frightened, and the presence of a supportive nurse can help them feel safer and more secure. It is important to balance the client’s need for space with the need for support and reassurance.

Choice D Reason:

Review the updated problem list with the client.

Reviewing the updated problem list is not appropriate during a panic attack. This action requires cognitive engagement and focus, which the client may not be capable of during an acute anxiety episode. The priority during a panic attack is to help the client calm down and manage their immediate symptoms, not to discuss or review problems.

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