A nurse is implementing a bladder training program for a client who had a stroke. Which of the following interventions should the nurse take first?

The correct answer is choice D. Document the client’s condition after every 15 minutes.

Choice A rationale:

Requesting a PRN restraint prescription for clients who are aggressive is not appropriate because restraints should only be used as a last resort and not on a PRN basis. Restraints should be used only when necessary to ensure the safety of the patient and others, and always with a specific, time-limited order.

Choice B rationale:

Removing the client’s restraint every 4 hours is not frequent enough. Restraints should be removed more frequently to assess the patient’s condition, provide care, and ensure that the restraint is still necessary.

Choice C rationale:

Attaching the restraint to the bed’s side rails is unsafe. Restraints should be attached to a part of the bed frame that moves with the patient to prevent injury.

Choice D rationale:

Documenting the client’s condition every 15 minutes is the correct guideline. Frequent documentation ensures that the patient’s condition is continuously monitored, and any changes can be addressed promptly to ensure safety and well-being.

A. The client has a decreased energy level.A decreased energy level can be a common symptom of many conditions, including terminal illnesses. While it can be associated with feelings of hopelessness, it is not necessarily an indication of it. Other factors like the illness itself, treatments, or emotional stress can contribute to low energy.

B. The client requests a second opinion.Requesting a second opinion is generally a sign that the client is still actively engaged in their care and is seeking more information or alternative options. It indicates hope or a desire for different possibilities rather than hopelessness.

C. The client wants to talk about the diagnosis with the nursing staff.Wanting to talk about the diagnosis with the nursing staff suggests that the client is processing the information and seeking support. Open communication is a positive coping mechanism and not typically an indication of hopelessness.

D. The client makes funeral arrangements.When a client makes funeral arrangements, it can be a sign that they are feeling hopeless about their situation and are preparing for the end of their life. While it is practical and sometimes necessary to make such arrangements, in this context, it can be seen as a manifestation of hopelessness.