A nurse is caring for a client who has physical restraints applied. The nurse determines that the restraints should be removed when which of the following occurs?
A.
The client states that he will harm himself unless the restraints are removed.
B.
The client demonstrates that he is oriented to person, place, and time.
C.
The client is able to follow commands.
D.
The client refuses to take his medication unless he is released.
The Correct answer and Explanation is:
Correct Answer: C. The client is able to follow commands.
Explanation:
Physical restraints are used as a last resort in healthcare settings to prevent clients from harming themselves or others. Restraints should only be applied when all other alternatives have failed, and they should be removed as soon as it is safe to do so. The decision to remove restraints is based on the client’s behavior, level of orientation, and ability to follow instructions that ensure their safety.
Option C: “The client is able to follow commands.”
This is the correct answer because it indicates that the client is now capable of controlling their behavior and can adhere to the safety guidelines set by the healthcare team. When a client can consistently follow commands, they are less likely to engage in harmful behaviors that originally necessitated the restraints. For instance, if the client can follow directions like not pulling at tubes or attempting to get out of bed unsupervised, the risks that required the restraints are mitigated. This shows that the client has regained a level of cognitive and behavioral control, making it safer to remove the restraints.
Option A: “The client states that he will harm himself unless the restraints are removed.”
This option is incorrect because a verbal statement of self-harm, especially linked to the removal of restraints, does not indicate that the client is safe without them. In fact, it may indicate an ongoing risk that justifies continued restraint use. The statement might be a form of manipulation or a reflection of the client’s current mental health status, both of which would warrant further assessment rather than immediate restraint removal.
Option B: “The client demonstrates that he is oriented to person, place, and time.”
While orientation is important, it alone does not determine whether a client is safe without restraints. A client might be oriented but still exhibit behaviors that are dangerous, such as attempting to get out of bed when at risk for falls. Therefore, orientation is a necessary but not sufficient criterion for removing restraints.
Option D: “The client refuses to take his medication unless he is released.”
This option is also incorrect because refusing medication as a condition for restraint removal could be a form of manipulation and does not indicate improved behavior or a reduction in risk. The primary concern with restraints is the client’s safety, not compliance with medication. The refusal could stem from frustration, but it does not mean the client is safe from self-harm or harm to others.
Conclusion:
The primary goal when using restraints is to maintain the client’s safety while minimizing harm. Restraints should be discontinued as soon as the client demonstrates they can maintain safety independently, which is best indicated by their ability to follow commands. This decision must be made with careful clinical judgment, prioritizing the client’s well-being and dignity while ensuring their safety and the safety of others.