The nurse is caring for a 7-year-old boy whose left leg is immobilized. What is the priority nursing intervention?
A) Enlist the assistance of a child life specialist.
B) Explain to the boy that he must keep his leg very still.
C) Apply a clove hitch restraint to the boy's left leg.
D) Explain that a restraint will be applied if he cannot hold still.
B
Response:
An explanation about the goal is necessary and appropriate for a 7-year-old child so he can understand what is required. In many cases, this will be all that is needed. Explaining that a restraint will be applied if the boy cannot hold still will likely be perceived as a threat or punishment. All alternative measures need to be tried before restraints are used. Enlisting the assistance of the child life specialist is not a priority.
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