A nurse is caring for a client who became physically aggressive and had to be placed in mechanical restraints. Which of the following actions should the nurse take while the client is in restraints?

Choice A reason: Persistent headache on oral contraceptives may indicate serious complications like stroke or hypertension, requiring immediate reporting to prevent life-threatening events. This is critical for timely intervention, ensuring client safety, and guiding potential medication adjustments in women using hormonal contraception for 6 months.

Choice B reason: Weight gain of 2.3 kg is common with oral contraceptives and not urgent, unlike persistent headache, which signals serious risks. Assuming weight gain requires reporting risks overlooking critical neurological symptoms, critical to avoid in ensuring safe monitoring of contraceptive side effects.

Choice C reason: Frequent nausea is a common contraceptive side effect, typically managed with counseling, not urgent like headache. Assuming nausea is priority risks delaying serious symptom evaluation, critical to prevent in ensuring timely reporting of potentially life-threatening complications in contraceptive users.

Choice D reason: Breast tenderness is a common, non-urgent side effect of oral contraceptives, unlike persistent headache, which may indicate stroke risk. Assuming tenderness is urgent risks missing critical symptoms, critical to avoid in ensuring proper monitoring and safety in clients on hormonal contraception.

Choice A reason: Having children at home is relevant for social support but less critical for occupational therapy than home layout, like a two-story home. Assuming children are priority risks overlooking functional adaptations, critical to avoid in ensuring tailored rehabilitation for clients post-amputation.

Choice B reason: Penicillin allergy is medical information, not directly relevant to occupational therapy, which focuses on functional adaptations for a two-story home. Assuming allergy is key risks diverting focus from rehabilitation needs, critical to prevent in supporting recovery post-amputation in occupational therapy planning.

Choice C reason: Reporting a two-story home is critical, as it impacts occupational therapy planning for mobility and daily tasks post-amputation, ensuring adaptations like stair aids. This is essential for functional independence, safety, and rehabilitation, supporting effective recovery and quality of life in clients with arm amputations.

Choice D reason: A parent in a nursing facility is unrelated to occupational therapy needs, unlike a two-story home, which affects mobility. Assuming this is relevant risks neglecting home adaptation needs, critical to avoid in ensuring functional rehabilitation and independence for clients post-amputation.