A nurse is applying a belt restraint to a client who has become physically aggressive. Which of the following actions should the nurse take?
A.
Apply the restraint under the client’s clothes.
B.
Tie the restraint to the railing of the client’s bed.
C.
Place the client in a sitting position.
D.
Ensure the restraint is placed across the client’s chest.
The correct answer and Explanation is :
The correct answer is A. Apply the restraint under the client’s clothes.
When using physical restraints, such as a belt restraint, it’s crucial to follow proper guidelines to ensure the client’s safety and comfort while maintaining compliance with ethical and legal standards. Here’s an explanation of why applying the restraint under the client’s clothes is the appropriate action:
Explanation:
- Avoiding Direct Skin Contact: Applying the restraint under the client’s clothes helps to prevent direct contact with the skin. This approach minimizes the risk of skin irritation, pressure ulcers, and discomfort that can result from the restraint’s material rubbing directly against the skin.
- Ensuring Proper Placement: Placing the restraint under the client’s clothes helps to ensure that the restraint is correctly positioned and not easily accessible to the client. It also helps to distribute the pressure more evenly across a broader area of the body, which can prevent localized injury or discomfort.
- Maintaining Dignity and Comfort: This method respects the client’s dignity and privacy by keeping the restraint less visible. It also contributes to the client’s comfort, which is essential for reducing agitation and distress during the use of restraints.
Why Other Options Are Less Appropriate:
- B. Tie the restraint to the railing of the client’s bed: Tying a restraint to the bed’s railing can be dangerous. It can result in potential injury if the client tries to move or if there is an unexpected movement of the bed. Additionally, it might not allow for quick release in case of an emergency.
- C. Place the client in a sitting position: The client’s position depends on the specific situation and needs to be assessed on an individual basis. The use of restraints should be guided by safety and the client’s condition rather than a predetermined position.
- D. Ensure the restraint is placed across the client’s chest: Restraints should not be applied across the chest as this could impede breathing and cause additional harm. The correct placement generally involves restraining the waist area while allowing freedom of movement of the arms and legs.
In summary, applying the restraint under the client’s clothes is the best practice to ensure safety, comfort, and proper adherence to ethical standards.