An individual was brought to the emergency room with impaired cognitive function. The patient's aggressive behavior and attempts to get out of bed present a safety issue. The nurse should first:
a. apply four-point restraints.
b. use a calm tone to orient the patient.
c. assign staff to stay in the room with the patient.
d. call for security guards to assist with controlling the patient.
B
Reality orientation is generally helpful to patients with cognitive impairment. A patient who is misinterpreting reality should be reoriented by a nurse who uses a calm manner and soothing voice. Reorientation is the least restrictive way of addressing the behaviors. Restraints or holding the patient down would increase agitation; assigning staff to stay with the patient continuously is not appropriate as an initial intervention.
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