Difficulty: Medium
Average Score: 62%
Simulated
A client has become physically aggressive toward staff and other clients. What action by the nurse will best assure the safety of the milieu while preserving the client's rights?
Correct answer
D
Rationale
Before applying restraints, the nurse must exhaust alternative measures to restraints such as a bed alarm, distraction, and a sitter. If the nurse determines that a restraint is necessary, its use is discussed with the client and family, and a prescription is obtained from the primary health care provider. The nurse should explain carefully to the client and family the indications for the restraint, the type of restraint selected, and the anticipated duration for its use. Sedation can be considered as a chemical restraint. The nurse avoids applying the restraint on a client who refused it to prevent client coercion and future charges of battery.