A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take?

The correct answer is choice A.

Choice A rationale:

Documenting the client’s condition every 15 minutes is a crucial part of using restraints. Regular documentation helps ensure the safety and well-being of the client, as it allows for continuous monitoring and timely intervention if necessary.

Choice B rationale:

Requesting a PRN (as needed) restraint prescription for clients who are aggressive is not a recommended practice. Restraints should only be used as a last resort and must be based on a thorough assessment of the client’s condition, not solely on their behavior.

Choice C rationale:

Attaching the restraint to the bed’s side rails is not recommended. This can increase the risk of injury to the client. Restraints should be attached to a part of the bed frame that moves with the client, such as the head or footboard.

Choice D rationale:

While it’s important to regularly check and adjust restraints for comfort and safety, there’s no specific guideline that restraints should be removed every 4 hours. The frequency of removal and repositioning will depend on the individual client’s condition and needs.

The correct answer is d. “Your desire to be an organ donor must be documented in writing.”

Rationale for Choice a:

• Statement:“Your name cannot be removed once you are listed on the organ donor list.”
• Rationale:This statement is incorrect.Individuals have the right to change their minds about organ donation at any time.They can have their names removed from the organ donor list by contacting the appropriate registry or organization.It's essential for nurses to provide accurate information to ensure informed consent and respect for patient autonomy.

Rationale for Choice b:

• Statement:“You must be at least 21 years of age to become an organ donor.”
• Rationale:This statement is also incorrect.The age requirement for organ donation varies by jurisdiction.In many places,individuals under 18 years of age can register as organ donors with parental consent.Nurses should be familiar with local regulations to provide accurate guidance.

Rationale for Choice c:

• Statement:“I cannot be a witness for your consent to donate.”
• Rationale:While it's true that nurses generally cannot act as witnesses for organ donation consent,the focus of the response should be on directing the client to the appropriate channels for documentation.Nurses can play a role in facilitating the process by providing information and resources to clients who express interest in organ donation.

Rationale for Choice d:

• Statement:“Your desire to be an organ donor must be documented in writing.”
• Rationale:This is the correct response.To ensure clarity and legal validity,organ donation preferences must be documented in writing.This documentation can be done through various means,such as registering with an organ donor registry,indicating preferences on a driver's license,or completing an advance directive.Nurses should emphasize the importance of written documentation to protect the client's wishes.