A female nurse walks into the hospital room of a 50-year-old male client, for the first time. The client is recuperating from knee surgery. The male client speaks little English and there are bed rails in place. The client has no pyjama bottoms on and he throws the sheet back to expose himself and then reaches out to grab the nurse. What should the nurse's immediate response be?
Select one:
a. Advise the client: "I see you are not dressed. I will be back in 10 minutes and will help you get more comfortable but only when you have your clothes on."
b. Seek a medical practitioner's order for interim physical restraint to prevent the client injuring himself and adhere to the ANMC National Competency Standards in this regard.
c. Leave the room immediately and report the incident to the clinical nurse consultant/unit coordinator.
d. Move out of the client's reach and then set about to assess the situation