A nurse in a clinic is reviewing laboratory reports for a group of clients. Which of the following diseases should the nurse report to the state health department?

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.

a. “The client is in the radiology department for a chest x-ray.”

This information is relevant as it informs the oncoming nurse about the client's current location and the reason for the absence from the unit. It helps maintain awareness of the client's whereabouts and the ongoing diagnostic process.

b. “The client’s partner came to visit him 2 hrs. ago.”

While it's important to document visitor interactions in the client's chart, informing about a visit from 2 hours ago during a change-of-shift report may not be as pertinent to immediate patient care as other information. This detail can be communicated through other means, such as the client's chart or communication log.

c. “The client has routine vital signs prescribed.”is not as critical to include in the change-of-shift report because it is standard practice and does not provide specific, immediate information about the client’s current status or any changes that need to be monitored closely.

d. “The client is the president of a local bank.”

While interesting, this information is not relevant to the client's current medical condition or care plan. It does not contribute to the immediate care needs of the client and can be considered extraneous during a change-of-shift report.