A client who was placed in restraints appears in the hallway an hour later and states, "I'm Houdini.… I can get out of anything. There could be trouble now." Which of the following is the best response to this client? A)"How are you feeling now?" B)"How did you manage to get out of the restraints?" C)Say nothing but signal to other staff that assistance is needed D)"What kind of trouble are you thinking about?"

Question

Quizplus · Accepted Answer

In this situation, the priority nursing action is to quickly and calmly assess this client's present risk for violence before implementing an intervention. This client's statement, "There could be trouble now," has multiple possible meanings (eg, Is the nurse "in trouble" as the restraints may not have been applied properly? Are the other clients in the unit "in trouble" as this client is out of restraints? Is this client "in trouble" due to thoughts of self-harm?). Seeking clarification of this client's statement is a therapeutic communication technique that will help the nurse determine the next steps in providing care. Mechanical restraints may be necessary only as a last resort for a client at high risk for violence, self-directed or other-directed. Clients placed in restraints must be observed and monitored frequently for: Assisting with hydration, elimination, and positioning Ensuring that circulation is not compromised Determining readiness for removal of restraints (Option A) It is important to ask this client about current feelings. However, in this situation, the priority is to clarify this client's statement. (Option B) This statement is immaterial; it is important to assess this client's current status. (Option C) Assistance from another staff member may be necessary if this client is still at high risk for violence; this client needs to be assessed first. Educational objective: A client at high risk for violence, self-directed or other-directed, may need to be placed in restraints as a last resort. Frequent monitoring and assessment through observation and use of therapeutic communication techniques will help determine if a client is ready to have restraints removed.

A Client Who Was Placed in Restraints Appears in the Hallway