Which situation indicates a need for the nurse to discuss the use of mitten restraints with the healthcare provider?
Explanation & Rationale
Rationale: A. A family member expresses concern about their relative "picking" at the nasogastric (NG) tube: Family concern should be acknowledged, but restraint use must be based on clinical necessity. The nurse can first implement non-restrictive interventions before considering restraints. B. A client is walking the halls at night rubbing his hands together: This behavior does not indicate harm to self or others or interference with medical devices. There is no justification for restraint, and doing so could violate patient rights and ethical standards. C. A 16-year-old boy swung his fist at the nurse: This may call for emergency behavioral restraints rather than mitten restraints. If the behavior poses a threat of violence, other forms of crisis intervention or behavioral management should be pursued first. D. A disoriented client removed the mesh-wrapped intravenous (IV) line for the second time: Mitten restraints may be considered when a client repeatedly removes critical lines or tubes, especially when cognitively impaired. This situation meets the clinical indication for discussing their use with the provider to prevent treatment disruption while ensuring safety.