A patient is brought to the ED by two police officers
The patient was found unconscious on the sidewalk, with his face and hands covered in blood. At present, the patient is verbally abusive and is fighting the staff in the ED, but appears medically stable. The decision is made to place the patient in restraints. What action should the nurse perform when the patient is restrained?
A) Frequently assess the patient's skin integrity.
B) Inform the patient that he is likely to be charged with assault.
C) Avoid interacting with the patient until the restraints are removed.
D) Take the opportunity to perform a full physical assessment.
Ans: A
Feedback:
It is important to assess skin integrity when physical restraints are used. Criminal charges are not the responsibility of the nurse and the nurse should still interact with the patient. A full physical assessment, however, would likely be delayed until the patient is not combative.
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