What actions will the nurse follow when using restraints for an older client in a long-term care facility? Select all that apply.
1. Use restraints for 2 hours or less.
2. Use restraints for emergency situations only.
3. Utilize waist restraints to prevent client falls.
4. Obtain a physician's order before using restraints.
5. Remove the client's eyeglasses when applying restraints.
1. Use restraints for 2 hours or less.
4. Obtain a physician's order before using restraints.
Explanation: 1. Restraints are now limited to short-term use of 2 hours or less.
2. Restraints may be necessary in other situations other than just in emergency situations.
3. Waist restraints are not proven to be the best approach to prevent client falls. Nurses are urged to develop alternatives to physical restraints such as addressing client and environmental factors.
4. Restraints are used only with a physician's order.
5. The nurse should ensure the client is wearing eyeglasses, which would reduce the need to use a restraint.
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