When caring for a client requiring the use of arm restraints to ...

[nevelica]

When caring for a client requiring the use of arm restraints to prevent the client from self-harm, the nurse would perform which of the following implementations?
 
  1. Assess the need for restraints every 24 hours.
  2. Remove the restraints for five minutes every four hours.
  3. Perform ROM on the restrained limbs once a shift.
  4. Offer food, fluid, and toileting every two hours.

Question 2

An appropriate initial action for the nurse to take when a client touches her or him inappropriately would be to Standard Text:
 
  What will be an ideal response?

[Viet Thy]

Answer to Question 1

4
Rationale 1: If the client is not NPO, basic care is offered every two hours. The need for restraints, ROM to the restrained limb, and removal of one restraint at a time are assessed or performed every two hours.

Answer to Question 2

Take the hand and move it away, use direct eye contact and say Don't do that.
Rationale : Avoid the client's room

[nevelica]

TYSM

[dyrone]

Thanks for the timely response, appreciate it