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    Ati rn comprehensive predictor 2023 proctored exam

    A nurse on a mental health unit is teaching a newly licensed nurse about the use of mechanical restraints. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

    Explanation & Rationale

    A. "I should ask the provider to write a prescription for mechanical restraints as needed.": Prescriptions for restraints must specify a time-limited duration and cannot be written as “as needed.” This ensures that the use of restraints is justified, monitored, and reevaluated according to legal and regulatory standards. B. "I should assess the client's skin integrity every 8 hours while in mechanical restraints.": Skin integrity should be assessed much more frequently—typically every 2 hours—to prevent pressure injuries, skin breakdown, and circulation issues associated with prolonged restraint use. C. "I should expect the provider to evaluate the client within 4 hours of restraint application.": For adults, the provider must evaluate the client within 1 hour of initiating restraints. Waiting 4 hours would not meet safety or regulatory requirements for ongoing assessment. D. "I should visually monitor the client continuously when in mechanical restraints.": Continuous visual monitoring is essential to ensure client safety, detect signs of distress, monitor for respiratory compromise, and prevent injury while the restraints are in place.

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