A nurse is reinforcing teaching about home safety needs for a toddler. Which of the following statements by the toddler's parents indicates an understanding of the teaching?

Rationale:

A. Administer haloperidol via the intramuscular route: Medication may be necessary for agitation, but administering it before assessing the client’s emotional state and safety is premature and could escalate distress.

B. Collect data regarding the client’s feelings: Assessing the client’s emotional state and reasons for pacing and clenched fists helps identify triggers, enabling the nurse to choose the least restrictive intervention and promote de-escalation.

C. Obtain assistance to apply wrist restraints: Restraints are a last resort to ensure safety and should only be used after less restrictive interventions have failed and when the client poses an immediate risk to self or others.

D. Move the client into the seclusion room: Seclusion is also a restrictive intervention requiring assessment of necessity. Moving the client without first gathering data and attempting de-escalation may violate client rights and worsen agitation.

Rationale:

A. Reinforce client teaching about walking with crutches: Teaching or reinforcing client education is a nursing responsibility and should not be delegated to assistive personnel. It requires assessment, evaluation, and knowledge of the client's learning needs and physical limitations.

B. Plan care for a client who has dysphagia: Care planning involves critical thinking and individualized assessment, which fall under the registered nurse’s scope of practice. Dysphagia management also requires knowledge of aspiration risk and appropriate interventions.

C. Transfer a client who is receiving radiation therapy to radiology: Transferring stable clients to departments such as radiology is within the scope of assistive personnel, as long as the client does not require specialized monitoring or assessment during the transfer.

D. Record urine output for a client who has a suprapubic catheter: Measuring and documenting urinary output is a routine task that assistive personnel can perform. The catheter type does not affect the ability to carry out this basic observation.

E. Measure vital signs for a client who requires contact precautions: Assistive personnel are trained to take vital signs and follow isolation protocols. Measuring vital signs under contact precautions is appropriate as long as proper PPE and hygiene practices are followed.