A nurse is assisting in the care of a client who was placed in mechanical restraints due to physical violence. Which of the following actions should the nurse take?

Rationale:

A. Paranoid personality disorder: This disorder is marked by distrust and suspicion of others, but it is not closely associated with the development of anorexia nervosa. It does not typically involve the rigid control over food and body image seen in eating disorders.

B. Schizotypal personality disorder: While schizotypal personality disorder involves social anxiety and eccentric behaviors, it is more aligned with psychotic spectrum disorders than with the rigid and perfectionistic traits commonly seen in anorexia nervosa.

C. History of attention deficit hyperactivity disorder: ADHD may be more associated with impulsive eating behaviors and a higher risk for binge eating or bulimia nervosa, rather than the restrictive and perfectionistic traits seen in anorexia nervosa.

D. History of obsessive-compulsive disorder: OCD is a significant risk factor for anorexia nervosa due to the overlap in obsessive thoughts and compulsive behaviors. Individuals with OCD often display rigid routines, perfectionism, and intrusive thoughts about food, body image, and control—all of which are common features in anorexia.

Rationale:

A. Offer the client fluids and toileting every 15 min: While regular offering of fluids and toileting is essential, the standard protocol is typically every 2 hours not every 15 minutes unless otherwise indicated. Overly frequent checks may not be feasible or necessary unless clinically justified.

B. Obtain a prescription before removing the restraints: Mechanical restraints are considered a restrictive intervention and require a physician's order for both application and removal. This ensures medical oversight and client safety.

C. Ensure the restraints are removed from the client within 6 hr: Time limits for restraints depend on the client’s age. For adults, a new order must be obtained every 4 hours, not 6. For children and adolescents (9-17 years), it's 2 hours, and for children under 9 years, it's 1 hour.

D. Place the client in prone position on a soft mattress: Prone restraint positions are not safe and are strongly discouraged due to risk of asphyxiation or injury. Restraints should always allow for safe positioning, typically with the client in a supine or semi-Fowler’s position.