An aggressive client was placed in four-point restraints and given an intramuscular dosage of
anxiolytic medication.
Systematic assessment to guide interventions during the period of restraint
should include (more than one answer may be correct)
A. hydration.
B. vital signs.
C. nutritional status.
D. elimination needs.
E. level of awareness.
F. range of motion and comfort needs.
A, B, C, D, E, F
Rationale: All the options should be assessed. Each pertains to biological and safety needs of the
client. Nurses must follow hospital protocol for care. Generally, clients should be observed for level
of consciousness at 15-minute intervals, given food at normal meal times or more often if they are
hyperactive, given fluids hourly, have vital signs taken at 4-hour intervals or less if medication
administration has caused hypotension, taken to the bathroom every 2 hours, and released from
restraint and given range of motion every 2 hours.
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