A nurse is caring for a client who was placed in four-point restraints by the nursing staff following an episode of violent behavior. Which of the following actions should the nurse take?

Keep staff interactions with the client to a minimum.

Provide range-of-motion exercises to all extremities every 2 hr.

Request the provider renew the prescription in 24 hr.

Document the client's behavior in the medical record every 1 hr.

Answer and Explanation

The Correct Answer is B

A.   Keeping staff interactions to a minimum may not be beneficial as the client might require regular monitoring and interaction to assess their condition and needs.
B.   When a client is restrained, it's crucial to prevent complications such as muscle stiffness and joint contractures. Range-of-motion exercises help maintain circulation, prevent discomfort, and preserve joint mobility. However, this is not the most important action.
C.   Restraints should only be used when absolutely necessary and prescribed by a provider. In many jurisdictions and healthcare facilities, the use of restraints requires a specific order that must be renewed periodically (often every 24 hours). This practice ensures that the need for restraints is continually reassessed and that they are not used longer than necessary.
D.   Accurate and frequent documentation is essential when a client is restrained. Documentation should include the client's behavior, physical assessments, interventions provided (such as medication administration or hygiene care), and responses to interventions. However, this is not the most important action.

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Correct Answer is A

Explanation

A. This response encourages the client to express their feelings and memories about their relationship with their deceased partner. It allows the client to talk about their emotions, reminisce about positive memories, and potentially share any unresolved issues or feelings of loss. This can be therapeutic as it provides an opportunity for the client to process their grief through storytelling and expression.
B. This response shifts the focus from the client's experience to the nurse's own experience. It can detract from the client's need to talk about their own feelings and may not be perceived as empathetic. While sharing personal experiences can sometimes create rapport, in this context, it may not be the most therapeutic approach as it might minimize the client's unique experience and emotions.
C. This response assumes a directive approach, suggesting what the client "should" do. While encouraging a return to routine activities can be beneficial in some cases, it may not be appropriate immediately after a significant loss. Grieving is a personal process, and the client may not be ready to engage in usual activities right away. It's important to assess the client's readiness and provide support tailored to their current emotional state.
D. This response minimizes the client's feelings by suggesting that their experience is universal. While it's true that many people experience sadness and grief after a loss, each individual's response is unique. This statement may invalidate the client's emotions and fail to acknowledge the depth of their distress. It's important to validate the client's feelings and provide reassurance that their emotions are normal in the context of grief.

A. "I can encourage my child to think about what they did that allowed this event to happen." B. "I should encourage my child to focus solely on the future." C. "I will have to do all I can to monitor my child's relationships." D. "I anticipate that my child will feel some self-blame."

Correct Answer is D

Explanation

A. This statement suggests a potential for victim-blaming or placing responsibility on the adolescent for the assault. It does not reflect a positive support system because it may contribute to feelings of guilt and shame in the adolescent. Victims of sexual assault should not be made to feel responsible for the actions of the perpetrator.
B. While encouraging the adolescent to focus on the future can be positive, solely focusing on the future without acknowledging or processing the trauma of the assault may invalidate the adolescent's current feelings and experiences. A supportive approach involves acknowledging and validating the adolescent's emotions and experiences, both past and present.
C. This statement may come from a place of concern for the adolescent's safety and well-being, which is understandable. However, it can also indicate a lack of trust or an overprotective stance that may not fully empower the adolescent to regain a sense of control over their life and decisions.
D. This statement demonstrates an understanding of common reactions and emotions experienced by individuals who have been sexually assaulted. Acknowledging that the adolescent may feel self-blame can be a way to open up discussions about these feelings and reassure the adolescent that they are not at fault. It shows empathy and readiness to support the adolescent emotionally.

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A nurse is caring for a client who was placed in four-point restraints by the nursing staff following an episode of violent behavior. Which of the following actions should the nurse take?

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Correct Answer is D

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