Question

A client with schizophrenia, who has a history of being placed in seclusion for physically assaulting other clients, is showing signs of increased agitation. The nurse observes that he's scraping his face and eyes with his fingernails and injuring himself. All nursing attempts to reduce this behavior have failed. What should the nurse do next?

A. Contact the physician and apply physical restraints as instructed by the physician.
B. Apply physical restraints to protect the client, then contact the physician for orders.
C. Place the client in seclusion and contact the physician for further orders.
D. Call security to restrain the client and put him in seclusion for the safety of the unit.

Answer 1

The nurse should contact the physician and apply physical restraints only as instructed by the physician to address the client's immediate self-harm risk and to ensure proper care and safety measures are followed.

Step-by-step explanation:

In the scenario where a client with schizophrenia is exhibiting increased agitation and self-injurious behavior, and all previous nursing attempts to reduce this behavior have failed, the next step would be A. Contact the physician and apply physical restraints as instructed by the physician. This action ensures that the client's self-harming behavior is immediately addressed to prevent further injury while seeking guidance and orders from the treating physician. Using restraints is a measure taken to protect the client when they are a danger to themselves or others, but it must be done following proper protocol and under a physician's direction to ensure the safety and rights of the client are respected. While placing the client in seclusion or calling security might seem like immediate solutions, these actions should only be taken under specific guidelines and typically require physician orders or institutional policies to be in place before execution. Thus, the nurse's priority is to safeguard the client's well-being while obtaining further instructions from a physician.