The nurse directs the intervention team who must take an aggressive client to seclusion. Other
clients have been removed from the area.
Before approaching the client, the nurse should ensure that
staff (more than one answer may be correct)
A. remove jewelry, glasses, and harmful items from their persons.
B. select the person who will communicate with the client.
C. quickly approach the client and take hold of the closest arm or leg.
D. move behind the client to use the element of surprise.
E. appoint a person to clear a path and open, close, or lock doors.
A, B, E
Rationale: Option A prevents injury to staff and the client. Option B: Only one person should
explain what will happen and direct the client. This may be the nurse or a staff member with a good
relationship with the client. Option E 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 client has been restrained. Option C: Each staff member should have an assigned limb rather than
just grabbing the closest. This system could leave one or two limbs unrestrained. Option D:
Approaching in full view of the client reduces suspicion.
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Which factor should be examined FIRST when the LP/VN is establishing priorities of care for a client?
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While attending a community health fair, the nurse observes the children of one family walking quietly behind the father with their mother and periodically shyly asking the father questions
The father responds gruffly and continues walking while the children and mother scurry behind to keep up. What does this observation indicate to the nurse? Select all that apply. A) The father is in a hurry. B) The father is the leader in the family. C) The children are not to bother the father. D) The children need discipline. E) The mother's role is to care for the children.
A liver transplant patient is receiving azathioprine (Imuran). What nursing goal is critical for this patient?
a. Maintain bed rest with minimal exertion. b. Minimize his risk for infection. c. Allow several visitors. d. Monitor vital signs every 15 minutes.