The nurse plans care for a patient who requires physical restraint. Which is a suitable goal for this patient?

Question

a. The patient remains free of any injury.
b. The nurse checks the restraint every hour.
c. The nurse uses the least restrictive re-straint.
d. The patient allows the nurse to apply re-straints.

Answer 1

A
When restraints become necessary, the patient must remain free of injury; thus the nurse plans frequent neurovascular checks and removes the restraint on a regular basis to inspect the skin for pressure points and breakdown and perform range-of-motion exercises to maintain joint flexibil-ity. Checking the restraint is a nursing intervention; it is not a goal because it is not patient cen-tered. Using the least restrictive restraint can defeat the purpose of a restraint. When a restraint is required, the nurse uses the proper restraint to keep the patient safe and facilitate the therapeutic regimen. This is not a suitable goal because it focuses on the nurse. If the patient or staff mem-bers' safety is at risk, the nurse applies restraints without the patient's permission.