An aggressive patient was placed in four-point restraints and given an intramuscular dosage of anxiolytic medication. Nursing care of the restrained patient should include: (Select all that apply.)
a. assessment of vital signs and hydration.
b. constant direct observation until release.
c. provision of fluids and finger foods.
d. opportunities for elimination at least hourly.
e. regular reassessment of mental status.
f. range-of-motion and comfort needs.
A, B, C, D, E, F
Patients in restraints are entirely dependent on others for their basic safety and all of their physiological needs. They are also at risk of injury from poor positioning that interferes with their circulation or airway. Therefore all restrained patients must be constantly observed to ensure they are safe and secure. They also are to be provided with adequate nutrition (straws for fluids and finger foods for solids ease intake), regular opportunities for elimination, repositioning or other interventions to provide for periodic range-of-motion exercise, regular assessment of mental status, and attention to other hygiene and comfort needs.
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