The nurse assesses that the client may need a restraint and recognizes

The nurse assesses that the client may need a restraint and recognizes that:

1. An order for a restraint may be implemented indefinitely until it is no longer re-quired by the client
2. Restraints may be ordered on an as-needed basis
3. No order or consent is necessary for restraints in long-term care facilities
4. Restraints are to be periodically removed to have the client reevaluated

ANSWER

ANS: 4
Restraints must be periodically removed, and the nurse must assess the client to determine if the restraints continue to be needed. Answer 1 is not a true statement. A physician’s order for re-straints must have a limited time frame. If the orders are renewed, it should be done so within a specified time frame according to the agency’s policy. Restraints are not to be ordered prn (as needed). The use of restraints must be part of the client’s medical treatment. An order or consent is necessary for restraints in long-term care facilities.