A nurse is caring for a client who is incontinent of urine. Which of the following actions should the nurse take?

A. “I’d like to hear your thoughts about giving yourself this medication.”: This response uses open-ended, therapeutic communication that invites the client to express concerns, fears, or misconceptions. It demonstrates respect for autonomy and helps build trust while allowing the nurse to assess readiness to learn. Understanding the client’s perspective is essential before providing education or problem-solving.

B. “You will suffer serious health issues if you don't take your medication.”: This response uses fear and threats, which can increase anxiety and resistance rather than promote cooperation. It does not encourage dialogue or address the client’s underlying concerns.

C. “Why don't you want to learn how to give yourself your medication?”: Questions beginning with “why” can feel accusatory or judgmental, causing the client to become defensive. Although the nurse needs to understand the client’s reluctance, this phrasing may inhibit open communication. A more neutral approach is preferred.

D. “Have you considered how your decision to refuse medication will affect your family?”: This response applies guilt and shifts the focus away from the client’s feelings and autonomy. It does not promote therapeutic communication or support informed decision-making. Using guilt can undermine trust and collaboration.

A. The restraint strap is tied into a knot: Restraints should be secured using a quick-release knot or buckle to allow rapid removal in case of an emergency. Tying a standard knot can prevent timely removal and is unsafe.

B. The skin under the restraint is cool and has changed color: Skin that is cool, discolored, or showing signs of pressure or impaired circulation indicates compromised perfusion and is a concerning finding that requires immediate intervention, not an expected outcome.

C. The restraint is attached to the side rails of the bed: Restraints should never be attached to side rails because this increases the risk of injury or asphyxiation if the client attempts to move. Safe restraint attachment is to the bed frame, not movable parts.

D. The nurse can insert two fingers under the restraint: Being able to slide two fingers under the restraint indicates that it is snug but not overly tight, allowing adequate circulation and minimizing risk of injury. This is the expected and safe finding when restraints are applied correctly.