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
Rationale: A. I should visually monitor the client continuously when in mechanical restraints: Continuous visual monitoring is required when a client is placed in mechanical restraints to ensure safety, assess physical and psychological well-being, and promptly address any complications such as impaired circulation or distress. B. I should ask the provider to write a prescription for mechanical restraints as needed: PRN (as needed) prescriptions for restraints are not permitted. A new, time-limited order must be obtained for each specific episode to ensure proper use and prevent misuse or overuse of restraints. C. I should expect the provider to evaluate the client within 4 hours of restraint application: For adult clients, the provider must evaluate the client face-to-face within 1 hour of applying restraints, not 4 hours. This rule ensures timely review of the necessity and appropriateness of the intervention. D. I should assess the client's skin integrity every 8 hours while in mechanical restraints: Skin integrity should be assessed at least every 2 hours or more frequently depending on facility policy. Waiting 8 hours increases the risk of skin breakdown and other complications.