NCLEX-RN

Category - Safety

A nurse is caring for an 88-year-old client who has a case of mild dementia. During the night, the client becomes agitated and combative. The nurse holds off restraining this client based on the understanding that:
  1. There is no physician order to allow restraint.
  2. There are negative connotations of restraint use.
  3. There is a PRN dose of anxiolytics for this client.
  4. Elderly clients can have many injuries when restrained.
Explanation
Answer: D - The use of restraints in elderly people is avoided because of the overwhelming injuries precipitated by its use. Use of restraints could result in vascular and neurologic damage, pressure ulcers, fractures, falls, contusion, emotional trauma, and death. Although physical and chemical methods of restraints are available, their use is avoided not because of their negative connotations but due to the overwhelming consequences of their use. Instead of restraints, facilities now prefer close monitoring and supervision and addressing the needs that provoked the unacceptable behavior.
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