Question

question 5 of 5
the nurse is caring for a client that is agitated and combative. what action(s) can the nurse take other than the use of physical restraints? select all that apply.
place all four side rails up.
provide a warm beverage.
use simple, clear explanations and directions.
provide a safe environment.
reduce stimulation, noise, and light.
distract and redirect in a commanding voice.

Explanation:

• Placing all four side rails up can be considered a form of restraint in some contexts (as it limits movement and can be confining), so this is not an appropriate non - restraint action.
• A warm beverage can have a calming effect.
• Simple, clear explanations and directions can help an agitated client understand what is expected and reduce confusion.
• A safe environment reduces the risk of injury from the client's own actions due to agitation.
• Reducing stimulation (noise, light) can help calm an over - stimulated (agitated) client.
• A commanding voice is likely to increase agitation rather than calm the client. A calm, soothing voice is more appropriate for distraction and redirection.

Answer:

B. Provide a warm beverage, C. Use simple, clear explanations and directions, D. Provide a safe environment, E. Reduce stimulation, noise, and light.