A nurse is assisting in the care of a client who is in restraints following an episode of violence. Which of the following information should the nurse document in the client's medical record? (Select all that apply.)

Providing opportunities for nutrition and toileting

Observing range of motion of client's extremities

Observation of the client once per hour

Attempts at less restrictive interventions

Names of staff members caring for the client

Answer and Explanation

Correct Answer : A,B,D,E

A.   It is essential to document the times when the client was offered opportunities for nutrition and toileting while in restraints. This includes offering food and fluids at regular intervals and assisting the client with toileting needs as required. Documentation ensures that these basic needs are met despite the restraint status.
B.   Documenting observations of the client's range of motion helps monitor for any signs of discomfort, circulation issues, or injury related to being in restraints. This documentation is crucial for ensuring the client's safety and well-being during restraint use.
C.   observation of the client should be conducted more frequently than once per hour, especially after an episode of violence, to closely monitor the client's condition and response to the restraints.
D.   Documenting attempts at less restrictive interventions shows that the healthcare team is actively working to minimize the use of restraints whenever possible. This might include attempts to de-escalate the client, use of medications, or other interventions aimed at reducing agitation or violence without resorting to physical restraints.
E.   It is important to document the names of staff members who are directly involved in the care of a restrained client. This ensures accountability and provides a clear record of who has been caring for the client during their restraint period.

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Correct Answer is A

Explanation

A. This is a proactive measure to enhance supervision and quick response to any signs of agitation, wandering, or attempts to get out of bed without assistance. Being closer to the nurses' station allows for more frequent monitoring and timely intervention to prevent falls.
B. Recreational therapy can play a significant role in enhancing the client's physical and cognitive abilities through tailored activities. Activities such as balance exercises, supervised walks, or engaging in structured programs can help improve mobility and reduce the risk of falls.
C. Lowering the window shade can reduce distractions and provide a calmer environment for the client. Excessive light or glare can sometimes contribute to confusion or disorientation in individuals with dementia. A more subdued environment can potentially decrease agitation and wandering behaviors, indirectly lowering the risk of falls.

D. The use of physical restraints, such as vest restraints, is generally discouraged in clients with dementia due to the potential for physical and psychological harm. Restraints can increase agitation, anxiety, and risk of injury, and they do not address the underlying causes of falls. The focus should be on environmental modifications, supervision, and non-pharmacological interventions.

A. "I can encourage my child to think about what they did that allowed this event to happen." B. "I should encourage my child to focus solely on the future." C. "I will have to do all I can to monitor my child's relationships." D. "I anticipate that my child will feel some self-blame."

Correct Answer is D

Explanation

A. This statement suggests a potential for victim-blaming or placing responsibility on the adolescent for the assault. It does not reflect a positive support system because it may contribute to feelings of guilt and shame in the adolescent. Victims of sexual assault should not be made to feel responsible for the actions of the perpetrator.
B. While encouraging the adolescent to focus on the future can be positive, solely focusing on the future without acknowledging or processing the trauma of the assault may invalidate the adolescent's current feelings and experiences. A supportive approach involves acknowledging and validating the adolescent's emotions and experiences, both past and present.
C. This statement may come from a place of concern for the adolescent's safety and well-being, which is understandable. However, it can also indicate a lack of trust or an overprotective stance that may not fully empower the adolescent to regain a sense of control over their life and decisions.
D. This statement demonstrates an understanding of common reactions and emotions experienced by individuals who have been sexually assaulted. Acknowledging that the adolescent may feel self-blame can be a way to open up discussions about these feelings and reassure the adolescent that they are not at fault. It shows empathy and readiness to support the adolescent emotionally.

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A nurse is assisting in the care of a client who is in restraints following an episode of violence. Which of the following information should the nurse document in the client's medical record? (Select all that apply.)

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Correct Answer is A

Explanation

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Correct Answer is D

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