An elderly client becomes confused, dislodges his I.V. access, and attempts to remove his indwelling urinary catheter. The client's primary nurse calls the physician and receives an order for soft wrist restraints. When the client's family insists that he not be restrained, the charge nurse informs the family that the family must provide an around-the-clock attendant for the client in order to avoid restraints. The family spokesman replies, "You find the attendant; that is your responsibility." It would be most appropriate for the charge nurse to respond:
A. It s your responsibility, as I have already stated to you. B. We can t be responsible for the client s safety if you won t let US restrain him. C. I think you re making the situation more difficult than it really is. D. I recommend family members arrange to stay with the client.
I recommend family members arrange to stay with the client.-rationale: offering the family a solution to the situation is therapeutic and can advance rapport with the family. it can also facilitate the problem-solving process, which involves the client, family, and staff. restating that finding an attendant is the familys responsibility and saying that family members are making the situation more difficult are confrontational approaches. such statements dont increase rapport with the family or enhance problem-solving. the staff cant renounce responsibility for the client if the family wont allow restraints.client needs category: safe, effective care environmentclient needs subcategory: management of carecognitive level: applicationreference: craven, r.f., and hirnle, c.j. fundamentals of nursing: human health and function, 5th ed. philadelphia: lippincott williams & wilkins, 2007, p. 375.