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Question

Difficulty: MediumSafe Use of Restraints and Safety Devices

An adult client recovering from a traumatic brain injury is experiencing severe psychomotor agitation and repeatedly attempts to remove their nasogastric feeding tube. The nurse is implementing measures to protect the medical device while adhering to safety guidelines. Arrange the following interventions in the correct sequence from least restrictive to most restrictive.

  1. 1Conduct a comprehensive assessment to identify and treat physiological triggers for the agitation.
  2. 2Implement environmental safety modifications and provide a diversionary activity.
  3. 3Camouflage the medical tubing using a long-sleeved gown or protective stockinette.
  4. 4Initiate continuous one-to-one observation with a trained patient sitter.
  5. 5Apply prescribed soft mitt restraints to prevent grasping of the device.

Answer

The correct sequence of interventions from least restrictive to most restrictive is: Assess for physiological triggers, provide a diversionary activity, camouflage the medical tubing, initiate continuous observation, and finally apply prescribed soft mitt restraints.
In accordance with safety and legal guidelines, restraints must be the intervention of last resort. The nurse must systematically exhaust less restrictive alternatives, beginning with physiological assessment to rule out treatable causes of delirium, progressing through environmental modifications and camouflaging devices, moving to direct human supervision, and only applying physical restraints when all other methods have proven ineffective.

Step-by-Step Solution

1
Analyze the clinical scenario.
The client is experiencing psychomotor agitation and attempting to remove an essential medical device, requiring interventions to protect the device while honoring client rights.
Establishing the clinical priority determines the trajectory of nursing care.
2
Apply the principle of the least restrictive alternative.
Interventions must progress from non-invasive, autonomous actions to increasingly restrictive measures.
Federal regulations and nursing standards mandate that restraints are an intervention of strict last resort.
3
Sequence the interventions based on the restriction hierarchy.
Assessment must precede environmental modification, followed by device camouflage, human supervision, and ultimately physical restraint application.
This sequence systematically rules out physiological causes and attempts all less restrictive measures before limiting the client's physical freedom.

Key Concept

Least Restrictive Restraint Alternatives
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Topics

Safe Use of Restraints and Safety Devices

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