Editing Management of Care – RN Practice Questions (section)

==Question 10==
A registered nurse is reviewing the care of a client in bilateral soft wrist restraints for violent behavior. Which finding requires '''immediate''' intervention?
# The restraints are secured to the movable portion of the bed frame with quick-release knots.
# The restraints have been released every 2 hours for range of motion and toileting.
# The order reads "soft wrist restraints as needed for agitation."
# A face-to-face evaluation was documented 40 minutes after the restraints were applied.

'''Answer:''' 3. The order reads "soft wrist restraints as needed for agitation."

''Rationale:'' As-needed and standing orders for restraint are prohibited. Each episode of restraint requires an individualized, time-limited order, and orders for violent or self-destructive behavior must be renewed at maximum intervals of 4 hours for adults 18 and older, 2 hours for ages 9 through 17, and 1 hour for children under 9. Option 1 describes correct technique: securing to the movable bed frame allows the restraint to move with the bed, and a quick-release knot permits rapid removal. Option 2 reflects appropriate monitoring. Option 4 meets the requirement that a face-to-face evaluation occur within 1 hour of initiation.