The nurse plans a restraint-free environment and cannot find activities to engage an agitated middle-aged client in activities. Which should the nurse implement to maintain the client's safety?
1. Request help from interdisciplinary team members.
2. Transfer the client to a private room to protect others.
3. Document that the client is uncooperative and hostile.
4. Ask the health care provider for a sedation prescription.
1
1. The nurse's expertise does not include occupational therapy, so the nurse collaborates with other experts to meet the client's safety and psychosocial needs. After assessing the client, the experts make recommendations and the nurse incorporates the activities into the client's plan of care.
2. Putting the client in a private room will decrease the risk of injury to other clients, but it will isolate the client, increase the need for distraction, and increase the risks to the staff and the client.
3. The nurse documents the client's behavior in objective terms to avoid labeling the client with inflammatory terms such as uncooperative or hostile. Instead, the nurse states, "Client did not ambulate this morning as prescribed" or writes, "client stated, ‘Stay away.'"
4. Sedation increases the risk of falls from potential adverse effects including hypotension, dizziness, and confusion.
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