Answer to Question 1
Answer: 2
Explanation: The nurse's best response is to tell the parent that the patient is in restraints to prevent the patient from harming himself or others. Restraints are not used simply because a patient was angry or to control behavior. All other less-invasive measures must be used prior to placing restraints and the patient must be a threat to self or others. Also, restraints are not used solely to keep a person from falling off the bed.
Answer to Question 2
Answer: 4
Explanation: Physical restraints are used only as a last resort, after all interventions have been tried and have been unsuccessful. The nurse must turn and reposition the patient in physical restraints at least every 2 hours to ensure the patient's skin integrity. The patient who is in physical restraints must be monitored constantly, not every hour, to ensure the patient's safety. All other possible interventions, not just pharmacological, must be attempted prior to the use of physical restraints. Additional interventions may include therapeutic communication techniques. Once physical restraints have been applied, the health care provider must assess the patient in restraints within 1 hour of restraint application.