The nurse is working in a long-term care facility on a locked Alzheimer unit. Which client assigned to the nurse might require restraints?

Question

1. The client who keeps getting out of bed at night and wandering the halls
2. The client who enters another client's room without reason and watches TV with the client in that room
3. The older adult client who spits at staff when they enter the room
4. The client who has numerous self-imposed scratches on the extremities

Answer 1

Correct Answer: 4

The client who has scratches might require a mitt restraint to prevent him from causing further injury. Wandering is a common behavior in clients with Alzheimer disease, and would not require restraints if the client is not harming himself or others. Bed or door alarms might be indicated to alert the staff when the client wanders, but the use of restraints would not be warranted. The client who is spitting would not require restraints, although staff should wear personal protective equipment when entering the room.