A client in restraints is assigned to a newly graduated nurse. The nurse understands that which of the following are true regarding restraints? Select all that apply.

  • Restraints can be chemical, mechanical, or physical.
  • Children under 9 years of age have a 30-minute time limit in restraints.
  • Bed rails are a form of restraint if used to prevent the client from leaving the bed.
  • Restraints must be assessed every 2 hours for proper application and continued need.
  • Once released, the client may be placed back in restraints for up to 24 hours if needed.
  • Active listening, diversionary techniques, and reducing stimulation are alternatives to restraints.
Numbers 1, 3, and 6 are correct.
A restraint is any mechanical, chemical, or physical device, equipment, or material that prevents or limits movement of any part of the client’s body. Bed rails are also a form of restraint, and many facilities have implemented policies barring the use of all four bed rails to keep clients in bed. Alternatives to restraints include active listening, diversionary techniques, reducing stimulation, and verbal interventions or asking the client for cooperation. Children under 9 years of age have a 1-hour time limit in restraints. Assessment of restraints and offering food, hydration, and toileting must be done regularly every 15 to 30 minutes. Many facilities mandate a trial release for clients in restraints. If restraints are removed, a new order must be obtained before replacing them. The use of restraints requires careful and complete documentation by the nurse.