The nurse conducts ongoing evaluation of the crisis situation to ensure the client's right to the least restrictive intervention. This means the assessment factor receiving the highest priority is:
1. The client's condition in comparison to the adequacy of the environment designed to prevent injury.
2. The client's mental status.
3. The client–staff ratio.
4. The comfort level of the environment.
1
Rationale: Decisions that impact the client's individual freedom are moral decisions. There must be consideration of what other interventions were attempted and what possibly could work, whether the client's behavior warrants a particular level of restrictive intervention, and how the level of the intervention will affect the client and the milieu. The client–staff ratio will not be a priority in determining the level of intervention. The client's mental status will be considered in conjunction with the environment. The comfort level of the milieu will not be a priority.
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