A nurse is reviewing a client's medical record. Which of the following findings should the nurse identify as a fall risk?

A. Involves respiratory therapy for altered breathing from severe anxiety levels: This behavior demonstrates collaboration with other healthcare professionals but does not directly relate to a team approach for managing mobility issues.
B. Delegates assessment of lung sounds to nursing assistive personnel: Delegation of tasks such as assessing lung sounds is a nursing responsibility but does not involve the broader team approach necessary for comprehensive care.
C. Becomes solely responsible for modifying activities of daily living: Handling all aspects of a patient's care individually does not reflect a team approach, which involves collaborating with various specialists.
D. Consults physical therapy for strengthening exercises in the extremities: This behavior exemplifies a team approach by involving physical therapy specialists to address mobility issues. It reflects collaboration with other disciplines to provide comprehensive care.

A. Use a square knot. Using a square knot is not recommended for securing restraints because it can be difficult to quickly release in an emergency. Instead, restraints should be secured with a quick-release tie to ensure they can be removed promptly if necessary.
B. Assess the extremity for circulation and neurological integrity every 2 hours. Regular assessment of the extremity is essential to ensure that the restraint is not impairing circulation or causing nerve damage. This frequent monitoring helps prevent complications and ensures the client’s safety.
C. Secure the restraint to the side rail. Securing restraints to the side rail is not recommended as it can cause injury or entrapment. The restraint should be secured to the bed frame or a fixed part of the bed that does not move or pose a risk to the client.
D. Assess restraints and skin integrity every 12 hours. Assessing restraints and skin integrity every 12 hours is inadequate. More frequent assessments, such as every 2 hours, are necessary to prevent skin breakdown and ensure that the restraints are not causing harm.