The nurse plans care for a client who requires physical restraint. Which is a suitable goal for this client?
1. The client remains free of any injury.
2. The nurse checks the restraint every hour.
3. The nurse uses the least restrictive restraint.
4. The client allows the nurse to apply restraints.
1
1. When restraints become necessary, the client must remain free of injury so the nurse plans frequent neurovascular checks and removes the restraint on a regular basis to inspect the skin for pressure points and breakdown and to perform range of motion exercises to maintain joint flexibility.
2. Checking the restraint is a nursing intervention; it is not a goal because it is not client centered.
3. 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 client safe and to facilitate the therapeutic regimen. This is not a suitable goal because it focuses on the nurse.
4. The client must permit the nurse to apply restraints; but if the client refuses, the nurse complies with the client's wishes and informs the client of the risks and benefits of applying and not applying restraints. If the client or staff members' safety is at risk, the nurse applies restraints without the client's permission.
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