Difficulty: Medium
Average Score: 79%
Simulated
A nurse is caring for a client who has wrist restraints after an episode of violent behavior. Which of the following actions should the nurse take?
Correct answer
A
Rationale
The correct answer is A: Remove one restraint at a time. This is the safest approach as it ensures the client's safety while allowing for gradual removal of restraints to assess their behavior and prevent sudden outbursts. Removing both restraints simultaneously can escalate agitation and pose a risk to the client and staff. Tying restraints to the side rail (B) can lead to entanglement and injury. Securing restraints with a square knot (C) may make it difficult to remove quickly in case of emergency. Removing restraints every 3 hours (D) is not as safe as removing one at a time based on the client's behavior.