Question
The nurse is caring for a combative and confused client with a fractured hip who is trying to get out of bed. What actions are appropriate for the nurse to take? Choose all that apply.
Give the client a sedative. Obtain a health care provider's order to restrain the client. Leave the client momentarily to obtain soft restraints from the clean supply room. Ask a family member to sit with the client. Apply restraints and leave the room to notify a health care provider.
Give the client a sedative. Obtain a health care provider's order to restrain the client. Leave the client momentarily to obtain soft restraints from the clean supply room. Ask a family member to sit with the client. Apply restraints and leave the room to notify a health care provider.
Answers
GPT-4o mini
In the scenario of caring for a combative and confused client with a fractured hip, the nurse has several options to ensure safety. The appropriate actions to take would include:
1. **Ask a family member to sit with the client.** - This can help provide comfort to the client and may deter them from attempting to get out of bed.
It is important to note that the following actions are **not appropriate** in this context:
- **Give the client a sedative.** - Administering medication without an order is inappropriate and could pose risks.
- **Obtain a health care provider's order to restrain the client.** - While obtaining an order is necessary before applying restraints, it should not be the immediate action taken without first assessing and trying less restrictive alternatives.
- **Leave the client momentarily to obtain soft restraints from the clean supply room.** - Leaving a confused and combative client unattended risks their safety and may lead to further injury.
- **Apply restraints and leave the room to notify a health care provider.** - This is unethical and unsafe. Restraints should only be used as a last resort and with the proper oversight and orders.
In summary, the only appropriate action from the choices provided is to ask a family member to sit with the client. The nurse should try to maintain the client’s safety through less restrictive means before considering restraints and should always follow facility policies regarding their use.
1. **Ask a family member to sit with the client.** - This can help provide comfort to the client and may deter them from attempting to get out of bed.
It is important to note that the following actions are **not appropriate** in this context:
- **Give the client a sedative.** - Administering medication without an order is inappropriate and could pose risks.
- **Obtain a health care provider's order to restrain the client.** - While obtaining an order is necessary before applying restraints, it should not be the immediate action taken without first assessing and trying less restrictive alternatives.
- **Leave the client momentarily to obtain soft restraints from the clean supply room.** - Leaving a confused and combative client unattended risks their safety and may lead to further injury.
- **Apply restraints and leave the room to notify a health care provider.** - This is unethical and unsafe. Restraints should only be used as a last resort and with the proper oversight and orders.
In summary, the only appropriate action from the choices provided is to ask a family member to sit with the client. The nurse should try to maintain the client’s safety through less restrictive means before considering restraints and should always follow facility policies regarding their use.