A nurse directs the intervention team who places an aggressive patient in seclusion. Before approaching the patient, which actions will the nurse direct team members to take? Select all that apply

a. Appoint a person to clear a path and open, close, or lock doors.
b. Quickly approach the patient and take the closest extremity.
c. Select the person who will communicate with the patient.
d. Move behind the patient when the patient is not looking.
e. Remove jewelry, glasses, and harmful items.


ANS: A, C, E
Injury to staff and the patient should be prevented. Only one person should explain what will happen and direct the patient. This may be the nurse or a staff member with a good relationship with the patient. A clear pathway is essential because those restraining a limb cannot use keys, move furniture, or open doors. The nurse is usually responsible for administering medication once the patient is restrained. Each staff member should have an assigned limb rather than just grabbing the closest. This system could leave one or two limbs unrestrained. Approaching in full view of the patient reduces suspicion.

Nursing

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