Difficulty: Medium
Average Score: 85%
Simulated
A nurse is rounding on a client with bilateral wrist restraints. Which finding would warrant the nurse to loosen the restraints?
Correct answer
C
Rationale
The correct answer is C: The client has cyanotic digits. Cyanotic digits indicate impaired circulation, which is a serious complication of restraints. Loosening the restraints in this situation is crucial to prevent tissue damage and ensure adequate blood flow. Choices A, B, and D do not directly address the potential harm to circulation caused by the restraints, making them incorrect. Full range of motion, attempting to remove the restraint, and denying discomfort do not necessarily indicate compromised circulation.