The nurse is attempting to assess a client who appears agitated. The client believes the nurse is trying to hurt him and is not cooperating with the nurse. What actions by the nurse are indicated? Standard Text: Select all that apply
1. Advise the client that the healthcare provider will be contacted unless the client complies.
2. Restrain the client using leather restraints.
3. Speak to the client in a calm voice.
4. Explain actions to the client as they are done.
5. Medicate the client.
3,4
Rationale 1: Advise the client that the healthcare provider will be contacted unless the client complies. Telling the client that the healthcare provider will be called in this manner may be viewed as threatening. This action may further upset the client.
Rationale 2: Restrain the client using leather restraints. The use of restraints in the psychiatric setting is limited. Restraints should be a last resort and only indicated when the client may harm himself or another individual. There is no indication either of these criteria has been met.
Rationale 3: Speak to the client in a calm voice. Speaking in a calm voice may help to diffuse the situation and relax the client.
Rationale 4: Explain actions to the client as they are done. Explaining activities to the client may help to reduce the fears being experienced by the client.
Rationale 5: Medicate the client. The administration of medications simply to quiet the client is considered a form of chemical restraint. In addition, it is beyond the scope of practice to medicate the client without specific orders from the healthcare provider.
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