Which of the following assessment findings is most critical in a client who is currently being re-strained with mechanical wrist restraints?
1. Angry, loud crying
2. Urinary incontinence
3. Reddened areas on wrists
4. Hands are cool to the touch
ANS: 4
While the use of any restraint may be associated with serious complications, including pressure ulcers, constipation, pneumonia, urinary and fecal incontinence, and urinary retention, the most serious are contractures, nerve damage, and circulatory impairment. The coolness of the client's hands indicates poor circulation and can result in permanent damage.
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