A nurse is caring for a school-age child who has conduct disorder and requires wrist restraints. Which of the following actions should the nurse take?
Monitor the child's vital signs every 15 min.
Obtain a prescription for the restraints within 2 hr of initiating them.
Have the child perform range-of-motion exercises every 3 hr.
Ensure three fingers will fit between the child's wrist and the restraint.
The Correct Answer is A
a. This option is most appropriate in the context provided, as frequent monitoring is essential for a child in restraints to ensure their safety and well-being.
b. Obtain a prescription for the restraints within 2 hr of initiating them. - This is incorrect because the standard requirement is to obtain a prescription within 1 hour of initiating the restraints, not 2 hours.
c. While range-of-motion exercises are important, they are typically recommended every 2 hours to prevent complications like contractures.
d. The correct procedure is usually to ensure that two fingers can fit between the wrist and the restraint to ensure it's not too tight or too loose.
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