Ati PN Mental Health 2023 Proctored Exam
A nurse is caring for a client who has become aggressive and requires the placement of wrist restraints to maintain the client's safety. Which of the following actions should the nurse take?
Explanation & Rationale
A. Restraints should be tied to the bed frame, not the side rails, to prevent injury if the rails are raised or lowered. B. Vital signs should be monitored more frequently than every 4 hours, according to facility policy, especially when restraints are applied. C. Quick-release knots should be used, not square knots, to allow rapid removal in an emergency. D. Monitoring circulation of the restrained extremities is essential to prevent complications such as impaired perfusion, nerve damage, or tissue injury.
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