Nclexrn Quiz: Restraints And Least Restrictive Alternatives
20 questions · exam conditions
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Restraints And Least Restrictive AlternativesQuestion 1 of 20

A 55-year-old client on a medical unit is receiving opioids after surgery and becomes increasingly drowsy and confused, attempting to climb out of bed. The nurse is considering restraints. Which action should the nurse take FIRST to ensure client safety?

Assess sedation level and respiratory status, evaluate pain control regimen, and implement fall precautions with close observation
Apply a belt restraint to prevent the client from standing
Keep the client in bed by raising all four side rails
Request a restraint order for the remainder of hospitalization to prevent future falls
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Nclexrn Quiz: Restraints And Least Restrictive Alternatives

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Question 1

A 55-year-old client on a medical unit is receiving opioids after surgery and becomes increasingly drowsy and confused, attempting to climb out of bed. The nurse is considering restraints. Which action should the nurse take FIRST to ensure client safety?

  1. Assess sedation level and respiratory status, evaluate pain control regimen, and implement fall precautions with close observation (correct answer)
  2. Apply a belt restraint to prevent the client from standing
  3. Keep the client in bed by raising all four side rails
  4. Request a restraint order for the remainder of hospitalization to prevent future falls
Explanation: This question tests knowledge of restraint use and least restrictive alternatives in opioid-related confusion. The principle of prioritizing client safety and autonomy involves addressing medication effects before restrictions. Assessing sedation, respiratory status, pain control, and implementing fall precautions with observation reflects the best balance between safety and least restriction by treating causes non-physically. Applying a belt (B) or raising rails (C) acts as restraints; requesting ongoing restraints (D) is premature. When choosing the least restrictive option, nurses should optimize medications and use precautions first. This prevents falls while monitoring side effects. In clinical practice, evaluate restraint alternatives by reviewing pharmacology and trialing adjustments to enhance alertness.

Question 2

A 60-year-old post-operative client becomes confused and repeatedly attempts to remove a surgical drain; the nurse applies soft wrist restraints per order. Which nursing action is the PRIORITY after restraints are applied?

  1. Secure the restraint ties to the bed frame to prevent movement during repositioning
  2. Perform and document circulation, skin integrity, and range-of-motion checks at the required intervals and offer toileting/fluids (correct answer)
  3. Leave the restraints in place until the next shift to avoid repeated agitation
  4. Ask the unlicensed assistive personnel to decide when restraints can be removed
Explanation: This question tests knowledge of restraint use and least restrictive alternatives post-application. The principle of prioritizing client safety and autonomy requires vigilant monitoring to prevent harm. Performing and documenting circulation, skin, range-of-motion checks, and offering toileting/fluids reflects the best balance between safety and least restriction by ensuring restraint safety. Securing to the bed frame (A) is incorrect; leaving until next shift (C) neglects reassessment; delegating removal (D) is inappropriate. When choosing the least restrictive option, nurses should monitor at required intervals for early removal. This minimizes duration and complications. In clinical practice, evaluate restraint alternatives by integrating monitoring with attempts to discontinue restraints promptly.

Question 3

An 81-year-old client in long-term care with dementia becomes agitated and tries to leave the unit after dinner; the client has arthritis but ambulates steadily with a cane. The nurse is considering restraints for "wandering." Which approach reflects the use of the least restrictive measure?

  1. Use a chemical restraint (sedative) each evening to prevent wandering
  2. Apply a vest restraint in bed after dinner to prevent the client from getting up
  3. Provide supervised walks after dinner, use distraction and meaningful activities, and ensure doors/alarms and identification measures are in place (correct answer)
  4. Place the client in a geri-chair and position it facing a wall to limit movement
Explanation: This question tests knowledge of restraint use and least restrictive alternatives for wandering in dementia. The principle of prioritizing client safety and autonomy promotes engagement over confinement. Providing supervised walks, distraction, meaningful activities, and ensuring alarms and identification reflects the best balance between safety and least restriction by fulfilling mobility needs. Using chemical restraints (A) or vest restraints (B) is more invasive; positioning in a geri-chair (D) limits freedom. When choosing the least restrictive option, nurses should incorporate routines like walks to reduce agitation. These interventions prevent elopement without physical barriers. In clinical practice, evaluate restraint alternatives by assessing daily patterns and integrating personalized activities for safety.

Question 4

A 73-year-old client with a history of stroke is admitted with dehydration and is confused; the client keeps trying to pull out the intravenous catheter. The nurse is considering mitt restraints. Which approach reflects the use of the least restrictive measure?

  1. Use mitts immediately and keep them on continuously for 24 hours
  2. First conceal and secure tubing, provide distraction and frequent reorientation, and consider mitts only if the client continues to tamper with the line (correct answer)
  3. Apply wrist restraints instead of mitts because they are more effective
  4. Stop intravenous fluids to eliminate the risk of line removal
Explanation: This question tests knowledge of restraint use and least restrictive alternatives for line protection. The principle of prioritizing client safety and autonomy involves trialing concealment before devices. Concealing tubing, providing distraction and reorientation, and considering mitts only if needed reflects the best balance between safety and least restriction by escalating gradually. Using mitts continuously (A) or wrist restraints (C) is premature; stopping fluids (D) compromises care. When choosing the least restrictive option, nurses should implement behavioral interventions first. This prevents tampering without full restriction. In clinical practice, evaluate restraint alternatives by documenting failed trials and selecting the minimal device necessary.

Question 5

A 44-year-old client on a psychiatric unit with schizophrenia is experiencing auditory hallucinations and is pacing; the client has a past history of striking staff during acute episodes but is currently following directions and has not made threats. Which approach reflects the use of the least restrictive measure?

  1. Place the client in four-point restraints preemptively due to history of aggression
  2. Offer a quiet space, use therapeutic communication, and maintain close observation while assessing for escalating agitation (correct answer)
  3. Lock the client in the room until the hallucinations stop
  4. Ask security to stand at the doorway continuously and refuse all client requests
Explanation: This question tests knowledge of restraint use and least restrictive alternatives in psychiatric settings. The principle of prioritizing client safety and autonomy involves de-escalating behaviors without unnecessary force. Offering a quiet space, using therapeutic communication, and maintaining close observation reflects the best balance between safety and least restriction by addressing hallucinations non-physically. Applying restraints preemptively (A) ignores current cooperation; locking the room (C) is seclusion without justification; using security restrictively (D) escalates tension. When choosing the least restrictive option, nurses should assess for escalation and use communication first. This promotes trust and prevents aggression. In clinical practice, evaluate restraint alternatives by documenting behaviors and trialing verbal interventions to maintain therapeutic alliances.

Question 6

A 70-year-old client with pneumonia is confused and repeatedly tries to get out of bed; the provider gives a verbal order for bilateral wrist restraints. Which action should the nurse take FIRST to ensure client safety and follow standards for restraint use?

  1. Apply the restraints and secure the ties to the side rail for quick removal
  2. Attempt least restrictive interventions (reorientation, toileting, bed alarm, closer observation) and use restraints only if these fail and risk remains imminent (correct answer)
  3. Ask the unlicensed assistive personnel to apply the restraints while the nurse completes documentation
  4. Apply restraints only after obtaining written consent from the family
Explanation: This question tests knowledge of restraint use and least restrictive alternatives for confused clients. The principle of prioritizing client safety and autonomy mandates trialing non-restraint options before following restraint orders. Attempting least restrictive interventions like reorientation, toileting, bed alarm, and observation reflects the best balance between safety and least restriction by addressing causes without immediate restraint. Applying restraints to side rails (A) is unsafe; delegating application (C) is inappropriate; requiring family consent (D) is not standard for competent adults. When choosing the least restrictive option, nurses should verify orders and implement alternatives first. This complies with standards and reduces restraint use. In clinical practice, evaluate restraint alternatives by documenting trials and reassessing behaviors to minimize restrictions.

Question 7

A 69-year-old client is 1 day post-operative and has a new onset of confusion; the client repeatedly attempts to remove the intravenous line. The nurse has reoriented the client, treated pain, and provided toileting, but the behavior persists. Which action should the nurse take FIRST before applying restraints?

  1. Apply restraints now because alternatives have already been attempted
  2. Assess for reversible causes of delirium (oxygenation, infection, medications) and implement closer observation such as a sitter or moving the client near the nurses' station (correct answer)
  3. Ask the family to sign consent for restraints and then apply them
  4. Delegate to the UAP to monitor the client and decide if restraints are needed
Explanation: This question tests knowledge of restraint use and least restrictive alternatives in post-operative delirium. The principle of prioritizing client safety and autonomy mandates exploring causes before restraints. Assessing for reversible delirium causes and implementing closer observation reflects the best balance between safety and least restriction by treating underlying issues. Applying restraints now (A) ignores alternatives; requiring consent first (C) delays; delegating (D) is inappropriate. When choosing the least restrictive option, nurses should investigate etiologies like infection. This reduces behaviors without restriction. In clinical practice, evaluate restraint alternatives by using diagnostic tools and observation to avoid unnecessary measures.

Question 8

A 62-year-old client with diabetes is admitted for sepsis and is acutely confused; the client repeatedly pulls off the oxygen mask and scratches at the intravenous site. After trying reorientation, pain control, toileting, and a sitter, the client continues and oxygen saturation drops to 84% when the mask is removed. What is the PRIORITY intervention to address the client's behavior?

  1. Apply the least restrictive restraint necessary per policy to maintain essential therapy and reassess frequently for removal (correct answer)
  2. Discontinue oxygen therapy to avoid the need for restraints
  3. Secure the oxygen mask with tape tightly around the client's head so it cannot be removed
  4. Delay action until the provider evaluates the client and writes a detailed plan
Explanation: This question tests knowledge of restraint use and least restrictive alternatives in sepsis management. The principle of prioritizing client safety and autonomy requires restraints as a last resort when vital therapies are at risk. Applying the least restrictive restraint per policy and reassessing frequently reflects the best balance between safety and least restriction after alternatives fail. Discontinuing oxygen (B) compromises care; taping tightly (C) is unsafe; delaying (D) risks hypoxia. When choosing the least restrictive option, nurses should select devices like mitts over full restraints if possible. This maintains therapy while minimizing restriction. In clinical practice, evaluate restraint alternatives by documenting oxygen levels and removing restraints when behaviors resolve.

Question 9

A 52-year-old client on a medical unit is confused and trying to get out of bed; the nurse asks the unlicensed assistive personnel (UAP) to "put the client in restraints if needed." Which action should the nurse take FIRST to ensure client safety and appropriate restraint use?

  1. Allow the UAP to decide because the UAP is at the bedside most often
  2. Assess the client personally for causes of agitation and implement least restrictive interventions before considering restraints (correct answer)
  3. Call the provider to request a restraint order before assessing the client
  4. Document that the client is confused and therefore automatically requires restraints
Explanation: This question tests knowledge of restraint use and least restrictive alternatives in delegation. The principle of prioritizing client safety and autonomy requires nurse-led assessments before restraints. Assessing personally for agitation causes and implementing least restrictive interventions reflects the best balance between safety and least restriction by ensuring proper evaluation. Allowing UAP decision (A) is unsafe delegation; calling for order first (C) skips assessment; documenting automatically (D) assumes need. When choosing the least restrictive option, nurses must lead with comprehensive assessments. This prevents unnecessary restraints. In clinical practice, evaluate restraint alternatives by avoiding delegation of judgment and prioritizing root cause analysis.

Question 10

A 78-year-old client in acute care with dementia is restless and repeatedly tries to climb out of bed; the nurse places the client in a room far from the nurses' station to "reduce noise." The client falls while attempting to get up. Which action should the nurse take FIRST to ensure client safety going forward?

  1. Request an order for full restraints for the remainder of hospitalization
  2. Implement a fall prevention plan with closer observation (near nurses' station), bed alarm, frequent rounding, and toileting assistance (correct answer)
  3. Complete incident documentation only; no immediate changes are needed
  4. Ask the family to stay overnight because staff cannot provide additional monitoring
Explanation: This question tests knowledge of restraint use and least restrictive alternatives after a fall. The principle of prioritizing client safety and autonomy involves enhancing monitoring post-incident. Implementing a fall prevention plan with observation, alarms, rounding, and toileting reflects the best balance between safety and least restriction by optimizing environment. Requesting full restraints (A) is excessive; documenting only (C) neglects action; relying on family (D) is inappropriate. When choosing the least restrictive option, nurses should adjust placement and interventions. This prevents recurrence without isolation. In clinical practice, evaluate restraint alternatives by analyzing incidents and implementing proactive safety measures.

Question 11

An 86-year-old long-term care resident with dementia becomes more confused at night and tries to get out of bed; the resident has bruises on both wrists from prior restraint use. Which approach reflects the use of the least restrictive measure?

  1. Reapply padded wrist restraints at bedtime and monitor them regularly to prevent the resident from climbing out of bed.
  2. Use a bed alarm, low bed position, adequate lighting, frequent rounding, and address comfort needs such as pain and toileting. (correct answer)
  3. Keep the resident in a wheelchair with a lap belt during the evening and keep the belt fastened from dinner until breakfast.
  4. Administer a sedative at bedtime and raise the side rails so the resident sleeps through the night and does not attempt to get up.
Explanation: The correct approach uses only environmental and comfort measures: a bed alarm, low bed position, adequate lighting, frequent rounding, and checking pain and toileting needs before bed. These interventions address common causes of nighttime confusion and falling without restricting movement. Reapplying padded wrist restraints at bedtime is still a physical restraint and would likely worsen the resident's existing wrist bruises. Keeping the resident in a wheelchair with a lap belt all evening and overnight is prolonged physical restraint and can lead to skin breakdown, contractures, or agitation. Giving a sedative at bedtime and raising side rails is chemical and physical restraint; it tries to suppress wandering rather than meet the resident's needs. The least restrictive approach must be tried first, and the only such approach here is the combination of alarms, positioning, lighting, rounding, and comfort care.

Question 12

A 58-year-old client is 1 day post-operative after abdominal surgery and has intermittent confusion. The provider writes an order: "Apply bilateral wrist restraints PRN for agitation." The client is currently calm, follows commands, and has not attempted to remove any lines during this shift. The nurse should QUESTION which order regarding restraints?

  1. "Apply bilateral wrist restraints PRN for agitation" (correct answer)
  2. "Implement a bed alarm and frequent rounding for safety"
  3. "Reorient the client frequently and ensure glasses/hearing aids are available"
  4. "Treat pain per protocol and reassess response"
Explanation: This question tests knowledge of restraint use and least restrictive alternatives, specifically regarding inappropriate restraint orders. The principle of prioritizing client safety and autonomy requires nurses to advocate against unnecessary restraint orders. Option A should be questioned because it orders restraints for "agitation" rather than specific dangerous behaviors, and the client shows no current indication for restraints (calm, following commands, no line removal attempts). Options B, C, and D all represent appropriate non-restraint interventions that should be implemented. The decision-making principle is that restraint orders must be specific to dangerous behaviors and based on current assessment, not potential future behaviors. A transferable strategy for evaluating restraint orders is to ask: Is this order based on current dangerous behavior? Are less restrictive measures being attempted first? Does the order specify clear criteria for use and discontinuation?

Question 13

A 29-year-old client on an inpatient psychiatric unit has schizophrenia and is experiencing auditory hallucinations. The client is pacing, yelling, and clenches fists but has not struck anyone; the client responds briefly to the nurse's voice and is willing to talk. What is the PRIORITY intervention to address the client's behavior while preserving autonomy?

  1. Initiate seclusion immediately because the client is pacing and yelling
  2. Use calm verbal de-escalation, offer a quieter environment, and assess for triggers while maintaining a safe distance (correct answer)
  3. Apply four-point restraints now to prevent escalation
  4. Wait to intervene until the client attempts to strike someone to justify restraint use
Explanation: This question tests knowledge of restraint use and least restrictive alternatives in psychiatric crisis intervention. The principle of prioritizing client safety and autonomy is crucial when managing escalating behaviors in mental health settings. Option B represents the best balance between safety and least restriction by using therapeutic communication, environmental modification, and assessment while maintaining safety - all without physical or chemical restraints. Option A prematurely uses seclusion for non-violent behavior; Option C jumps to the most restrictive intervention without attempting de-escalation; Option D dangerously delays intervention until violence occurs. The decision-making principle for choosing the least restrictive option in psychiatric care prioritizes verbal intervention and environmental changes before any form of restraint. A transferable strategy for evaluating restraint use in psychiatric settings is to follow the de-escalation hierarchy: verbal intervention, environmental modification, voluntary medication, and only then consider restraints if imminent danger exists.

Question 14

A 64-year-old client in the intensive care step-down unit is intubated and lightly sedated, intermittently reaching toward the endotracheal tube when awakening. The nurse has already provided reorientation, secured tubing, and attempted distraction; the client continues to reach for the tube and cannot follow commands consistently. Which approach reflects appropriate restraint use while maintaining safety and dignity?

  1. Apply the least restrictive restraint needed to protect the airway, obtain the required order, and perform ongoing neurovascular checks and release per policy (correct answer)
  2. Apply four-point restraints and keep them on continuously until extubation without reassessment
  3. Tie soft restraints to the side rail with a double knot to prevent loosening
  4. Use restraints only after the family signs a consent form, regardless of immediate airway risk
Explanation: This question tests knowledge of restraint use and least restrictive alternatives in critical care settings with life-sustaining equipment. The principle of prioritizing client safety and autonomy acknowledges that protecting artificial airways may necessitate restraints after other measures fail. Option A correctly describes appropriate restraint use: applying the least restrictive option needed, obtaining required orders, and following monitoring protocols including regular neurovascular checks and scheduled releases. Option B uses excessive restraint without reassessment; Option C describes unsafe application techniques; Option D delays necessary intervention for administrative reasons when immediate safety is at risk. The decision-making principle recognizes that restraints may be the least restrictive effective option when protecting life-sustaining equipment after other measures fail. A transferable strategy for evaluating restraint use in critical care is to ensure proper application technique, continuous reassessment for reduction or removal, and strict adherence to monitoring protocols.

Question 15

A 72-year-old client is 6 hours post-operative after a hip fracture repair on an acute care unit. The client is disoriented to place, repeatedly reaches for the urinary catheter and intravenous line, and attempts to climb out of bed despite instructions; vital signs are stable and the client reports pain 7/10. Which action should the nurse take FIRST to ensure client safety while using the least restrictive approach?

  1. Apply bilateral wrist restraints immediately to prevent removal of lines
  2. Assess the client's orientation and complete a full neurologic assessment before intervening
  3. Treat pain and implement nonrestraint measures (bed alarm, frequent rounding, reorientation, and move lines out of reach) and evaluate response (correct answer)
  4. Ask the unlicensed assistive personnel (UAP) to decide whether restraints are needed and to apply them if the client continues reaching
Explanation: This question tests knowledge of restraint use and least restrictive alternatives in post-operative care. The principle here is prioritizing client safety and autonomy by addressing underlying causes before considering restraints. Option C is correct because it addresses the client's pain (a common cause of post-operative delirium), implements multiple non-restraint safety measures, and allows evaluation of their effectiveness before escalating to more restrictive interventions. Option A incorrectly jumps to restraints without attempting less restrictive measures; Option B delays intervention when immediate safety measures are needed; Option D inappropriately delegates restraint decisions to UAP, which is outside their scope. The decision-making principle is to always address modifiable factors (pain, environment, orientation) and implement least restrictive measures first. A transferable strategy is to use the hierarchy: assess causes, treat underlying issues, implement environmental modifications, increase supervision, and only then consider restraints if all else fails.

Question 16

A 63-year-old client in the intensive care unit is intubated and lightly sedated; the client intermittently reaches toward the endotracheal tube when awakening. The nurse has tried reorientation and covering the tubing, but the behavior continues and the client is at risk of self-extubation. What is the PRIORITY intervention to address the client's behavior?

  1. Apply soft wrist restraints per policy and obtain the required provider order, then monitor circulation and skin integrity frequently (correct answer)
  2. Tie the client's wrists to the bed frame using a sheet, securing the wrists individually and checking the ties frequently
  3. Wait until the client's family arrives to ask for permission to use restraints, then decide whether to apply them after discussion
  4. Document that restraints are not permitted in this setting and continue reorienting the client hourly without additional interventions, including medication
Explanation: The priority is to protect the client's airway while using the least restrictive measure that works. Since reorientation and covering the tubing have failed, applying soft wrist restraints is appropriate—but only with a provider order, per policy, and with frequent checks of circulation and skin integrity to prevent complications. This action immediately reduces the risk of self-extubation. Tying the wrists to the bed frame with a sheet is not an approved restraint method; it can cause injury and lacks the required order and monitoring. Waiting for family to authorize restraints is inappropriate because the nurse must act in the patient's best interest when there is imminent risk; family cannot give medical permission. Documenting that restraints are not permitted is factually wrong, and continuing reorientation alone does not address the repeated reaching for the tube, leaving the client at high risk. The correct answer is to proceed with safe, ordered soft wrist restraints and monitor the client closely. Restraints are not a first-line option, but when less restrictive measures are exhausted, they are justified to prevent harm. Obtain an order and reassess frequently for removal.

Question 17

A 76-year-old client in acute care with a urinary tract infection is delirious, repeatedly pulls at the oxygen tubing, and attempts to get out of bed. The client's oxygen saturation drops to 86% when the nasal cannula is removed; after reorientation, toileting, and moving equipment out of reach, the client continues to remove oxygen and becomes increasingly agitated. Which action should the nurse take FIRST?

  1. Document the behavior and reassess the client in one hour to see whether the delirium improves before using a restraint.
  2. Apply a vest restraint without a provider order because removal of oxygen is dangerous and continue close monitoring.
  3. Request a provider order for the least restrictive restraint and apply it per policy while continuing close monitoring. (correct answer)
  4. Delegate to the UAP to decide which type of restraint to use, apply it, and monitor the client's response.
Explanation: After reorientation, toileting, and moving equipment out of reach did not stop the behavior, delaying another full hour before intervening leaves the client at risk of repeated oxygen-cannula removal and hypoxia. Applying a vest restraint without a provider order skips the required authorization and violates restraint policy. Delegating to the UAP the decision about which restraint to use is also wrong because restraint decisions require licensed nursing judgment and are not within UAP scope. The safest first action is to request a provider order for the least restrictive restraint, apply it per policy, and continue close monitoring. This provides immediate protection for the client while preserving the legal and ethical requirement to use the least restrictive effective intervention.

Question 18

A 90-year-old client in long-term care with moderate dementia frequently attempts to stand from a wheelchair without locking the brakes; the client has a history of falls but becomes agitated when physically restricted. Which approach reflects the use of the least restrictive measure?

  1. Use a wheelchair seatbelt and keep it fastened at all times
  2. Implement a toileting schedule, ensure the wheelchair brakes are locked, use a chair alarm, and provide supervised mobility (correct answer)
  3. Use a vest restraint during daytime hours to prevent the client from standing
  4. Move the client to a secluded area to minimize triggers for agitation
Explanation: This question tests knowledge of restraint use and least restrictive alternatives in dementia care. The principle of prioritizing client safety and autonomy emphasizes avoiding agitation from restrictions while preventing falls. Implementing a toileting schedule, ensuring wheelchair brakes, using a chair alarm, and providing supervised mobility reflects the best balance between safety and least restriction by supporting independence with safeguards. Using a seatbelt (A) or vest restraint (C) is more restrictive; secluding the client (D) isolates and may increase distress. When choosing the least restrictive option, nurses should integrate alarms and supervision to match the client's mobility level. These measures reduce fall risks without causing agitation. In clinical practice, evaluate restraint alternatives by observing client responses to interventions and adjusting for individual tolerances.

Question 19

An 84-year-old client in a long-term care facility has Alzheimer disease and ambulates independently with a walker; over the past 2 days the client has attempted to exit through an alarmed door and was found outside once. The client becomes anxious in the late afternoon but is calm when engaged in activities. Which approach reflects the use of the least restrictive measure?

  1. Apply a waist restraint in the wheelchair during peak wandering hours to prevent elopement
  2. Place the client in a room with the door closed and restrict visitors to reduce stimulation
  3. Implement a scheduled walking program with supervision and engage the client in structured afternoon activities (correct answer)
  4. Administer a sedative medication as needed for wandering per family request
Explanation: This question tests knowledge of restraint use and least restrictive alternatives for clients with Alzheimer disease. The principle of prioritizing client safety and autonomy emphasizes promoting independence while mitigating risks like wandering. Implementing a scheduled walking program with supervision and engaging the client in structured afternoon activities reflects the best balance between safety and least restriction by addressing anxiety through engagement rather than confinement. Applying a waist restraint (A) is overly restrictive and limits mobility; closing the door and restricting visitors (B) isolates the client and may increase agitation; administering sedatives per family request (D) is a chemical restraint and not least restrictive. When choosing the least restrictive option, nurses should prioritize activity-based interventions that match the client's routines and needs. These approaches reduce wandering by fulfilling the client's desire for movement and stimulation. In clinical practice, evaluate restraint alternatives by observing behavioral patterns and integrating therapeutic activities to enhance safety without physical limitations.

Question 20

A 79-year-old client in a rehabilitation unit has Parkinson disease and is at risk for falls; the client tries to get up quickly to use the bathroom and has nearly fallen twice. The provider writes an order: "Keep all side rails up at all times." The nurse should QUESTION which order regarding restraints?

  1. "Keep all side rails up at all times." (correct answer)
  2. "Implement a toileting schedule and ensure assistive devices are within reach."
  3. "Use bed and chair alarms and perform frequent rounding."
  4. "Consult physical therapy for mobility training and transfer techniques."
Explanation: This question tests knowledge of restraint use and least restrictive alternatives in fall prevention. The principle of prioritizing client safety and autonomy involves questioning orders that constitute restraints without justification. The order to keep all side rails up at all times should be questioned as side rails can be considered restraints and increase injury risk. The other orders (B, C, D) promote least restrictive measures like toileting, alarms, and therapy. When choosing the least restrictive option, nurses should advocate for environmental and supportive interventions. This ensures ethical compliance and client mobility. In clinical practice, evaluate restraint alternatives by assessing fall risks and implementing interdisciplinary plans without defaulting to barriers.