Difficulty: Medium
Average Score: 86%
Simulated
Wrist restraints have been prescribed for a client who is continuously pulling at the gastrostomy tube. The nurse develops a care plan and should determine that which findings would be negative outcomes related to the use of restraints? Select all that apply.
Correct answer
A,B,C,F
Rationale
A physical restraint is a mechanical or physical device used to immobilize a client or extremity. The restraint restricts freedom of movement. Negative outcomes in the use of restraints include signs of impaired skin integrity such as redness or skin breakdown; altered neurovascular status such as cyanosis, pallor, coldness of the skin, or complaints of tingling, numbness, or pain; increased confusion, disorientation, or agitation; or injuring staff. Client verbalization of the reason for the restraints and the client's inability to reach the gastrostomy tube with his or her hands are expected outcomes.