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Zorluk: ZorUse of Restraints and Safety Devices

A client admitted with severe pneumonia and chronic obstructive pulmonary disease (COPD) begins exhibiting sudden, severe agitation and repeatedly attempts to remove their continuous positive airway pressure (CPAP) mask. The assistive personnel (AP) informs the practical nurse (PN) that the client is uncooperative and requests permission to apply soft wrist restraints to maintain the essential oxygen therapy. Which action should the PN take FIRST?

  1. Instruct the AP to maintain continuous direct observation of the client while the PN assesses the client's oxygen saturation and respiratory effortCevap
  2. B
    Obtain bilateral soft wrist restraints and apply them immediately, then contact the healthcare provider to secure a formal prescription
  3. C
    Document the client's noncompliance and reassure the AP that sudden confusion is an expected progression of chronic lung disease exacerbations
  4. D
    Authorize the AP to apply the physical restraints, provided the AP has documented facility competency in safety device application

Cevap

Instruct the AP to maintain continuous direct observation of the client while the PN assesses the client's oxygen saturation and respiratory effort.
The correct action addresses both immediate safety and physiological needs by implementing a less restrictive alternative (direct observation) while the nurse investigates the root cause of the agitation. Sudden agitation in a respiratory patient strongly indicates acute hypoxia; therefore, assessing oxygenation takes priority before considering any restrictive devices.

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1
Analyze the client's sudden presentation of severe agitation and attempts to remove respiratory equipment.
Recognize that sudden confusion and restlessness in a client with compromised respiratory function are classic early clinical indicators of hypoxia.
Prioritizing physiological needs (Airway, Breathing, Circulation) is critical before attributing agitation to a strictly behavioral issue that requires restraint.
2
Evaluate the AP's request to apply physical restraints to maintain the CPAP mask.
Determine that applying restraints is a measure of absolute last resort and cannot be initiated before exhausting less restrictive alternatives.
Federal guidelines, legal boundaries, and nursing standards mandate that physical restraints only be used when non-restrictive alternatives have failed to protect the client from harm.
3
Formulate the priority nursing intervention that balances safety protocols with physiological assessment.
Assign the AP to stay at the bedside for direct visual observation (a less restrictive alternative) while immediately conducting a focused respiratory assessment.
This intervention maintains client safety without prematurely applying restraints and targets the most likely underlying cause of the agitation.

Anahtar Kavram

Prioritizing least restrictive alternatives and physiological assessment prior to restraint application
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Konular

Use of Restraints and Safety Devices

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