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Difficulty: MediumSafe Use of Restraints and Safety Devices

An adolescent client admitted to an acute behavioral health facility begins throwing furniture and physically threatening peers. After verbal de-escalation and pharmacological interventions fail to calm the client, four-point mechanical restraints are applied to prevent immediate severe injury. Which action must the registered nurse implement next?

  1. Initiate continuous, in-person observation of the client for the duration of the restraint use.Answer
  2. B
    Secure the restraint straps to the adjustable side rails of the bed using square knots.
  3. C
    Contact the healthcare provider to obtain a PRN (as-needed) prescription for mechanical restraints.
  4. D
    Delegate the ongoing assessment of peripheral circulation and respiratory status to the unlicensed assistive personnel.

Answer

Initiate continuous, in-person observation of the client for the duration of the restraint use.
When mechanical restraints are applied for violent or self-destructive behavior, strict safety standards require continuous, in-person observation of the client. This one-to-one monitoring is critical to immediately detect respiratory compromise, impaired circulation, or changes in psychological status, ensuring the restraints can be removed at the earliest possible safe moment.

Step-by-Step Solution

1
Identify the type of restraint indication described in the clinical scenario.
The client is exhibiting violent, self-destructive behavior that poses an immediate physical threat.
Different restraint indications (medical-surgical vs. violent/behavioral) have distinct regulatory requirements for monitoring and order renewal.
2
Determine the safety and monitoring requirements specific to violent behavioral restraints.
Standards require continuous, face-to-face observation by a trained staff member.
Continuous monitoring ensures the client's airway and circulation are not compromised and allows for rapid removal once the client is no longer an imminent threat.
3
Evaluate the remaining options against legal and safety standards for restraints and delegation.
Using square knots on side-rails, obtaining PRN orders, and delegating clinical assessments to unlicensed assistive personnel (UAP) are all severe safety violations.
Eliminating unsafe practices isolates the correct evidence-based nursing action.

Key Concept

Management of Violent and Behavioral Restraints
Estimated Time:1m 30s
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Topics

Safe Use of Restraints and Safety Devices

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