In light of the failure of alternatives, a nurse has been forced to physically restrain an agitated client. Which of the following actions should the nurse perform when applying and maintaining the restraints?
A) Tie the client's hand restraint to the bed frame rather than the side rail.
B) Obtain a physician's order for the restraints within 24 hours.
C) Ensure the client is under continuous surveillance while restrained.
D) Choose a restraint device that best minimizes the client's mobility.
Ans: A
Restraints should be tied to the frame of the bed rather than to the side rails. A physician's order is needed for restraints, except in emergencies when an order must be obtained within one hour of application. Frequent assessment of the client is needed, but continuous surveillance is not necessarily required. The least restrictive type of device that allows the greatest mobility, while still ensuring safety, is chosen.
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