Question

An adolescent client on a drug treatment unit becomes angry and pulls the refrigerator from the wall and then throws the microwave. After the client fails to respond to redirection, the healthcare provider prescribes restraints. Which assessment should the nurse include in the client's record while the client is in restraints?

A. Responsiveness to painful stimuli.
B. Pupils equal, round and reactive.
C. Range-of-motion and circulation.
D. Speech patterns and processes.

Answer 1

The nurse should assess the client's responsiveness to painful stimuli, pupils, and range-of-motion and circulation while they are in restraints.

Step-by-step explanation:

When a client is in restraints, the nurse should assess their:

1. Responsiveness to painful stimuli: The nurse needs to assess if the client is responsive to painful stimuli as it can indicate their level of consciousness and neurological function.
2. Pupils equal, round and reactive: The nurse should assess the client's pupils to ensure they are equal in size, round in shape, and reactive to light. This can provide information about their neurological status.
3. Range-of-motion and circulation: It is important to assess the client's range of motion and circulation to ensure that the restraints are not causing any physical harm or compromise to their blood flow.