A nurse from a medical-surgical unit is floating to a postpartum unit. Which of the following clients is an appropriate assignment for the nurse to accept?

A. The client spends most of their day sleeping: Excessive sleep is more characteristic of depressive episodes in bipolar disorder. While fatigue can contribute to risk in some contexts, it does not directly indicate increased injury risk from manic behaviors.

B. The client is easily distracted by external stimuli: Distractibility is a hallmark of mania and can lead to impulsive or unsafe actions, such as leaving dangerous objects within reach, wandering, or starting multiple activities at once. This significantly increases the client’s risk for injury.

C. The client withdraws from group activities: Social withdrawal is more associated with depressive states. While it may affect engagement or mood, it does not inherently increase risk for injury due to manic behavior.

D. The client will only eat finger foods: Preferring finger foods may indicate impulsivity or hyperactivity but does not directly correlate with a substantial risk for injury. Safety risks are more closely tied to distractibility, poor judgment, and impulsive actions during mania.

A. Document in the client's medical record every 15 min: Frequent documentation is required to monitor the client’s safety, physical and psychological status, and ongoing need for restraints. This includes checking circulation, skin integrity, respiratory status, and mental condition. Documentation every 15 minutes ensures compliance with regulatory standards and provides a detailed record of care while the client is restrained.

B. Offer toileting to the client every 4 hr: Clients in restraints should be offered toileting, hydration, and nutrition more frequently than every 4 hours, generally every 1–2 hours, to prevent complications such as skin breakdown, urinary retention, or dehydration. Waiting 4 hours is unsafe and does not meet standard restraint care guidelines.

C. Remove the restraint when the client falls asleep: Restraints should not be removed solely based on sleep. Continuous monitoring is essential, and restraints are only removed or adjusted based on the client’s behavior, safety status, and provider orders. Sleep does not automatically indicate that the client is safe to be unrestrained.

D. Request that the provider write an as-needed prescription for restraints: Restraints cannot be prescribed on an as-needed basis. They must be ordered with specific parameters including type, duration, and reason for use. Using restraints without a proper order or relying on as-needed instructions is outside legal and professional practice standards.