When caring for a client in mechanical restraints, which action should the nurse take?

When caring for a client in mechanical restraints, which action should the nurse take?

• A. Document in the client's medical record every 15 minutes.
• B. Remove the restraints if the client calms down.
• C. Increase the client's restraint periods for safety.
• D. Report the restraints to the physician after 1 hour.

Answer: (A)

When caring for a client in mechanical restraints, regular documentation is essential to ensure the client's safety and the justification for ongoing restraint use. Documenting in the client's medical record every 15 minutes allows the nursing staff to observe and record the client's physical status, psychological condition, and response to the restraints. This practice supports accountability and ensures that the care provided is aligned with facility policies and legal requirements. Continuous monitoring and documentation provide a clear record that can be reviewed by other healthcare professionals, which is important in evaluating the effectiveness of the restraints and the need for ongoing use. This approach not only safeguards the client's rights but also assists in making informed decisions about their care, including the potential removal of restraints if the client's condition improves.

When caring for a client in mechanical restraints, regular documentation is essential to ensure the client's safety and the justification for ongoing restraint use. Documenting in the client's medical record every 15 minutes allows the nursing staff to observe and record the client's physical status, psychological condition, and response to the restraints. This practice supports accountability and ensures that the care provided is aligned with facility policies and legal requirements.

Continuous monitoring and documentation provide a clear record that can be reviewed by other healthcare professionals, which is important in evaluating the effectiveness of the restraints and the need for ongoing use. This approach not only safeguards the client's rights but also assists in making informed decisions about their care, including the potential removal of restraints if the client's condition improves.