A nurse is caring for a client who is aggressive toward other clients and has been placed in wrist restraints. After obtaining a prescription for restraints from the provider, which of the following actions should the nurse take?
Explanation & Rationale
A. Document the client's behavior once every hour: Documentation of a client in restraints should occur more frequently, typically every 15 to 30 minutes, so once-per-hour documentation does not meet safety and regulatory standards. B. Keep the client in restraints until the prescription expires: Restraints should be removed as soon as the client no longer poses a risk, even if the prescription has not yet expired. Prolonged use increases physical and psychological risks. C. Conduct a debriefing regarding the client with the unit staff: Debriefing after a restraint episode allows the care team to discuss the circumstances, evaluate interventions, and plan strategies to prevent future aggression. It also helps support staff and promotes ethical, safe care. D. Request an evaluation of the client within 12 hr of application of restraints: Evaluation by a qualified provider should occur much sooner—usually within 1 hour for adults—to ensure that the use of restraints is appropriate and safe.