Medication is administered to a client who has been placed in restraints after a sudden violent episode, and his EPSs subside. Restraints can be removed when:

Question

Options

• AThe physician orders it
• BA therapeutic alliance has been established, and violent behavior subsides
• CThe violent behavior subsides, and the client agrees to behave
• DThe nurse deems that removal of restraints is necessary

• A
  7% (2)
• B
  79% (22)
• C
  4% (1)
• D
  11% (3)

Explanation

(A) The physicianmayorder release of restraints, but prior to that, the client must meet criteria for (B) While the client is still restrained, but after violent behavior has subsided, a therapeutic bridge is built. This alliance encourages dialogue between nurse and client, allowing the client to determine causative factors, feelings prior to loss of control, and adaptive alternatives to violence. (C) If the client only "agrees to behave" after violent behavior subsides, he has developed no insight into cause and effect of violence or his response to stress. (D)Removal of restraints occurs only when the client meets the criteria for release, not just because the nurse says it is necessary.

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