A nurse is documenting client care in the nurses' notes and notices that a space was left blank. Which of the following actions should the nurse take?

A. Apply restraints according to the facility's standing order: Restraints should never be applied based on a standing order. Each use of restraints requires a specific, immediate provider order following a thorough assessment of the situation.

B. Obtain a PRN prescription for restraints from the provider: PRN (as-needed) orders for restraints are not appropriate. Restraints must be ordered specifically when the need arises, after evaluating less restrictive measures.

C. Stand in front of the client to block them from others in the room: Standing directly in front of a combative client can escalate the situation and put the nurse at risk of injury. Maintaining a safe distance and using de-escalation techniques are safer strategies.

D. Ensure there are enough staff members available for assistance: Ensuring sufficient staff presence is critical when a client becomes combative. It helps ensure the safety of the client, other clients, and staff members, and allows for a coordinated response if physical intervention becomes necessary.

A. Recommend frequent hot baths: Hot baths can exacerbate symptoms in clients with multiple sclerosis by increasing fatigue and worsening muscle weakness due to a rise in core body temperature. Clients are usually advised to avoid overheating and use cooling strategies instead to manage their symptoms.

B. Encourage the client to restrict performing range-of-motion exercises: Range-of-motion exercises are important in maintaining joint flexibility, muscle strength, and overall mobility. Restricting these exercises could lead to increased stiffness, weakness, and decreased functional ability in clients with multiple sclerosis.

C. Monitor the client's ability to perform ADLs: Monitoring the client's ability to perform activities of daily living is essential because multiple sclerosis often leads to progressive physical limitations. Regular assessment helps in planning appropriate interventions, promoting independence, and adjusting care as the disease progresses.

D. Initiate contact precautions: Contact precautions are not necessary for clients with multiple sclerosis because it is not an infectious disease. Multiple sclerosis is an autoimmune, neurodegenerative condition that requires supportive care rather than infection control measures.