A nurse is collecting data from a client who is experiencing ketoacidosis. Which of the following manifestations should the nurse expect to find?

A. The restraint is attached to the side rails of the bed: Restraints should never be attached to the side rails because moving the rails could cause injury to the client. Restraints must be secured to a stationary part of the bed frame to prevent tightening, which could lead to impaired circulation or nerve damage if the bed position changes.

B. The restraint strap is tied into a knot: Tying the restraint strap into a knot is unsafe because knots are difficult to untie quickly in an emergency. Quick-release ties or slipknots are recommended to ensure the client can be released rapidly if needed, reducing the risk of injury or complications from prolonged restraint.

C. The nurse can insert two fingers under the restraint: Being able to insert two fingers under the restraint indicates that it is properly applied—not too tight to impair circulation, and not too loose to be ineffective. This ensures client safety by allowing adequate blood flow and reducing the risk of skin breakdown or nerve injury.

D. The skin under the restraint is cool and has changed color: Coolness and discoloration under a restraint are signs of impaired circulation and require immediate intervention. These findings are abnormal and suggest that the restraint is too tight, potentially leading to tissue ischemia, nerve damage, or pressure injuries if not promptly addressed.

A. Ask the client to identify what made them upset: The first action should be to assess and de-escalate the situation using therapeutic communication. Asking the client to verbalize their feelings can help reduce agitation, promote self-awareness, and prevent escalation.

B. Assist the client with understanding their needs: Helping the client understand their needs is important but comes after first addressing and calming their immediate emotional agitation through assessment and supportive conversation.

C. Place the client in seclusion: Seclusion is a last-resort intervention when the client poses a danger to themselves or others and less restrictive measures have failed. It should not be the first action without attempting de-escalation techniques.

D. Administer lorazepam IM: Administering medication is appropriate if non-pharmacological interventions fail. However, medication should not be the first response before attempting verbal de-escalation strategies in an agitated client.