Mr. Valencia, 83 years old, is confused after hip replacement and family asks about restraints. What should the practical nurse explain?

Mr. Valencia, 83 years old, is confused after hip replacement and family asks about restraints. What should the practical nurse explain?

• A. Restraining your father will only make him more agitated.
• B. We do not restrain clients anymore, as it is against the law.
• C. Would it be possible to have a family member stay with him until he is less confused?
• D. Would you like me to call the doctor to get an order for restraints for your father?

Answer: (B)

The situation tests understanding that restraints are not used as a routine intervention and must be tightly controlled by law and policy. Modern practice emphasizes minimizing any physical restraint because it can cause harm, increase agitation, and restrict a person’s rights. They require a physician’s order and must be justified only after exploring safer, less restrictive options. So explaining to the family that we do not restrain clients anymore, as it’s governed by law and ethics, is the appropriate stance. It communicates that safety is kept up through other means first, and that restraints would only be considered with proper orders and as a last resort. If risk of harm remains, the nurse would implement nonrestrictive measures (keeping the patient safe with closer supervision, familiar faces, reorientation, a calm environment, bed or chair alarms, and involving a family member to stay with him) and then consult the physician for an order if unavoidable. The other statements either imply restraint as a routine or suggest obtaining an order without first exhausting safer alternatives, which is not aligned with current practice.

The situation tests understanding that restraints are not used as a routine intervention and must be tightly controlled by law and policy. Modern practice emphasizes minimizing any physical restraint because it can cause harm, increase agitation, and restrict a person’s rights. They require a physician’s order and must be justified only after exploring safer, less restrictive options.

So explaining to the family that we do not restrain clients anymore, as it’s governed by law and ethics, is the appropriate stance. It communicates that safety is kept up through other means first, and that restraints would only be considered with proper orders and as a last resort. If risk of harm remains, the nurse would implement nonrestrictive measures (keeping the patient safe with closer supervision, familiar faces, reorientation, a calm environment, bed or chair alarms, and involving a family member to stay with him) and then consult the physician for an order if unavoidable. The other statements either imply restraint as a routine or suggest obtaining an order without first exhausting safer alternatives, which is not aligned with current practice.