A nurse is caring for a client who frequently attempts to remove his IV catheter. A family member requests that the nurse apply restraints. Which of the following responses should the nurse make?

Choice A reason : Conducting 15-minute checks can be part of the safety measures for a client at risk of self-harm, but it may not be sufficient for someone who is actively hearing voices commanding self-harm and refusing to engage in safety planning. These checks are less intensive and may not provide the immediate intervention needed to ensure the client's safety¹.

Choice B reason : Encouraging the client to express feelings related to suicide is an important therapeutic intervention that can provide insight into the client's emotional state and risk factors. However, if the client is actively psychotic and not engaging in safety planning, this approach alone may not be enough to ensure immediate safety¹.

Choice C reason : Placing the client on one-to-one observation is the most direct and immediate intervention to ensure safety when a client is experiencing psychotic features and is at risk of self-harm. This level of observation means that the client is never alone, and a staff member is always present to intervene if the client attempts self-harm¹.

Choice D reason : Obtaining an order for locked seclusion can be considered if other less restrictive measures are not sufficient to ensure the client's safety. However, it is generally a last resort due to the potential for negative psychological effects and should only be used when absolutely necessary and when other interventions have failed¹.

Choice A reason: Encouraging interaction with others by having the client share a room might be overwhelming for a client experiencing hypomanic episodes. Hypomania can involve irritability and impulsivity, making shared spaces potentially stressful. It's important to balance social interaction with the need for a controlled environment¹.

Choice B reason: Providing a calm atmosphere by placing the client in a private room can be beneficial for someone experiencing hypomanic episodes. A private room can reduce overstimulation and help manage symptoms like restlessness, agitation, and sleep disturbances. It allows the client to have a quiet space to retreat to, which can be crucial in managing mood swings¹².

Choice C reason: While a cheerful environment may seem beneficial, having bright drapes in the client's room could potentially contribute to overstimulation. Clients with hypomania are often sensitive to environmental stimuli, so it's important to keep the setting subdued to avoid exacerbating symptoms¹.

Choice D reason: Promoting access to activities by assigning the client to a room near the dayroom can be a double-edged sword. While it facilitates engagement in structured activities, which can be therapeutic, it also increases the risk of overstimulation due to the proximity to a potentially busy and noisy area. Careful consideration of the client's current state is necessary when making this decision¹.