A nurse is discussing the use of mechanical restraints with a newly licensed nurse. Which of the following situations should the nurse include as an indication for placing a client in mechanical restraints?

A. Risperidone (Risperdal):

Risperidone is an atypical antipsychotic and generally has a lower propensity for causing anticholinergic side effects compared to typical antipsychotics.

B. Lithium (Lithobid):

Lithium is a mood stabilizer used primarily for bipolar disorder and does not typically cause anticholinergic side effects.

C. Buspirone (Buspar):

Buspirone is an anxiolytic medication and does not have significant anticholinergic properties. It tends to have fewer side effects compared to other medications used for anxiety.

D. Fluphenazine (Prolixin):

Fluphenazine is a typical antipsychotic medication and belongs to the phenothiazine class, which is known to have notable anticholinergic effects. These effects can include dry mouth, constipation, blurred vision, urinary retention, and cognitive impairment.

A. Self-destructive behavior despite alternative interventions: Mechanical restraints may be considered when a client poses an immediate risk of harm to themselves, and alternative interventions have been ineffective or are not feasible.

B. Discipline for throwing objects at staff: Mechanical restraints are not appropriate as a form of discipline. Restraints should only be used when there is an imminent risk of harm to the client or others.

C. Punishment for verbally abusing other clients: The use of restraints as a form of punishment is not ethical or appropriate. Restraints should be employed solely to prevent harm, not as a disciplinary measure.

D. Coercion to take prescribed medications: Coercion to take medications is not a valid reason for using mechanical restraints. Alternative approaches, such as therapeutic communication or discussing the need for medications with the client, should be explored.