A nurse in the newborn nursery is providing care for four newborns. For which of the following events should the nurse plan to complete an incident report?

A) Administer PRN haloperidol IM to the client:

Administering haloperidol is not the first-line intervention for managing behavioral disturbances in clients with dementia, especially in response to acute agitation. While antipsychotic medications like haloperidol may be prescribed in some cases, they should be used judiciously due to the risk of adverse effects, particularly in elderly clients. Additionally, administering medication should not be the first action taken without attempting non-pharmacological interventions.

B) Engage the client in a repetitive activity as a distraction:

This is the most appropriate initial intervention when dealing with an agitated client with dementia. Engaging the client in a repetitive, calming activity can help redirect their focus and reduce agitation. Simple, familiar tasks or activities tailored to the client's preferences can be effective in providing comfort and reducing distress.

C) Apply wrist restraints to the client:

Using physical restraints should be avoided unless absolutely necessary for the safety of the client or others. Restraints can cause physical and psychological harm, increase agitation, and compromise the client's dignity and autonomy. Therefore, restraint use should be a last resort and implemented only after other interventions have been attempted and deemed ineffective or when there is an imminent risk of harm.

D) Place the client in a seclusion room:

Seclusion should not be used as an initial intervention for managing agitation in clients with dementia. Seclusion can exacerbate distress and increase feelings of isolation and fear, which may escalate agitation further. It should only be considered as a last resort for managing severe agitation or aggression when all other interventions have failed and there is a risk of harm to the client or others.

A) Ask ambulatory clients to help to move clients in wheelchairs:

While enlisting the help of ambulatory clients to assist those in wheelchairs may seem logical, it is not typically recommended as it could pose safety risks to both parties during an evacuation. Assistive personnel should be trained to prioritize their own safety and the safety of others during evacuation procedures, following established protocols for assisting clients with mobility impairments.

B) Place dry towels around the bases of doors:

Placing dry towels around the bases of doors is a recommended fire evacuation procedure to prevent smoke from entering the room. This action helps create a barrier to smoke inhalation and can buy time for evacuation or rescue efforts. It is important to use dry towels or clothing to avoid fueling the fire and to minimize the passage of smoke.

C) Carry bedridden clients to safety by lifting them onto your back:

Carrying bedridden clients on one's back during a fire evacuation is not a safe or feasible method, especially for assistive personnel who may not have the physical strength or training to perform such tasks. Evacuating bedridden clients should be done using appropriate evacuation equipment such as evacuation sleds or sheets, following facility protocols and guidelines.

D) Aim the extinguisher at the top of the fire:

While using a fire extinguisher is an important aspect of fire safety training, aiming the extinguisher at the top of the fire is not always the correct approach. The appropriate technique for using a fire extinguisher depends on the type of fire and the specific instructions provided with the extinguisher. It is essential for assistive personnel to receive proper training on fire extinguisher use and to follow established procedures during emergencies.