Which of the following assessment findings is most critical for a client who is currently being restrained with mechanical wrist restraints?
a. Angry, loud crying
b. Urinary incontinence
c. Reddened areas on wrists
d. Hands are cool to the touch
D
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 concerns are contractures, nerve damage, and circulatory impairment. The coolness of the client's hands indicates poor circulation and can result in permanent damage.
Angry, loud crying is a concern for the client, but it is not the most critical concern of the client with mechanical wrist restraints.
Urinary incontinence is a concern for the client, but it is not the most critical concern of the client with mechanical wrist restraints.
Reddened areas on the wrists are a concern for the client, but it is not the most critical concern for the client with wrist restraints.
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