Restraint (29 Questions)

1. You are working on a geriatric medicine unit. Mr. Tremblay, an 84-year-old patient with moderate Alzheimer’s dementia, has been wandering into other patients' rooms and attempting to leave the unit via the fire exit. He is unsteady on his feet and has a high risk of falling. The night shift nurse suggests, "We should just put a pelvic restraint (Posey vest) on him tonight so he doesn't fall and break a hip. We are too short-staffed to watch him constantly."

Question:
According to the ethical principle of using the least restrictive means, what is your priority nursing action before considering the restraint? *

Apply the vest immediately because safety from falls takes precedence over freedom of movement.

Call the physician to obtain a PRN order for the restraint to have it ready if needed.

Attempt alternative measures such as moving the patient closer to the nursing station, engaging him in a folding activity, or using a bed alarm.

Administer a dose of Lorazepam (Ativan) to help him sleep, as chemical restraint is safer than physical restraint.

2. Mrs. Gauthier, a 72-year-old patient, is admitted with urosepsis and delirium. She is agitated and continuously attempts to pull out her Foley catheter and IV line. After attempting distraction and camouflage without success, you receive an order to apply soft wrist restraints. You applied them 30 minutes ago.

Question:
To ensure patient safety and prevent neurovascular injury, what specific assessment must be performed and documented at this time? *

Remove the restraints completely to allow full Range of Motion (ROM) exercises.

Check the skin temperature, color, sensation, and capillary refill of the hands distal to the restraints.

Assess the patient’s level of orientation to see if the delirium has cleared.

Call the family to obtain consent for the restraints.

3. You are caring for Mr. Roy, a large man who is currently intoxicated and becoming physically aggressive toward staff in the Emergency Department. Verbal de-escalation has failed. The physician orders "Physical restraints PRN (as needed) for agitation."

Question:
How should you respond to this medical order? *

Accept the order and apply the restraints immediately to protect the staff.

Accept the order but wait until he actually hits someone to use it.

Contact the physician to clarify that "PRN" orders for restraints are not legally valid; a specific order based on a current assessment is required.

Ask the security guard to decide when the restraints are necessary.

4. Mrs. Lefebvre, 88, is a frail patient with severe osteoporosis. Her daughter is very concerned about her mother falling out of bed. The daughter insists, "Please pull up all four side rails on the bed. I want to make sure she stays inside."

Question:
What is the correct nursing response regarding the use of four full side rails? *

"I will do that immediately; it is the safest way to prevent a fall."

"Using all four rails is considered a restraint and actually poses a high risk of entrapment and serious injury."

"We can only use four rails if the doctor writes a prescription for it."

"I will put them up, but I have to pad them with pillows first."

5. Mr. Dubé is admitted to the ICU on a ventilator. He is waking up and reaching for his endotracheal tube. The team decides that control measures are necessary to protect the airway. You are deciding between applying "Mittens" or "Wrist Restraints."

Question:
According to the hierarchy of restrictiveness, which option should be selected first? *

Wrist restraints, because they are the most secure way to prevent extubation.

Mittens, because they prevent grasping the tube but allow the patient to move his arms.

Chemical sedation (Propofol), because it renders the patient unconscious.

A chest restraint, to prevent him from sitting up.

6. You enter the room of Mrs. Paquette, an elderly patient who was placed in a vest restraint (Posey) 2 hours ago due to severe wandering and intrusion into other rooms. You find Mrs. Paquette sleeping peacefully in her chair.

Question:
What is the appropriate nursing action regarding the restraint while the patient is sleeping? *

Leave the restraint on to ensure she doesn't wander off if she wakes up suddenly.

Tighten the restraint slightly to ensure she doesn't slide down in the chair while sleeping.

Wake her up to perform a neurological assessment.

Remove the restraint immediately while she is supervised or asleep, as the behavior necessitating the restraint (wandering) is not currently present.

7. Mr. Gagnon, 55, is admitted with alcohol withdrawal and is hallucinating. He is extremely agitated and screaming. The physician orders Haloperidol (Haldol) 5 mg IM specifically to "make the patient sleep and stop the screaming" because he is disturbing the unit.

Question:
How is this medication administration classified in this specific context? *

It is a standard therapeutic anxiolytic treatment for withdrawal.

It is a necessary safety measure for the patient's heart rate.

It is an inappropriate order because Haloperidol is not used for alcohol withdrawal.

It is a chemical restraint because the intent is to restrict behavior/movement for staff convenience or social order."

8. You are mentoring a nursing student. The student is applying a quick-release knot to secure a wrist restraint to the bed frame. The student ties the restraint to the movable part of the bed frame (the part that moves when the head of the bed is raised).

Question:
Why is this the correct technique? *

It allows the patient to pull against the frame for exercise.

It makes it harder for the patient to reach the knot to untie it.

It ensures that if the head of the bed is raised or lowered, the restraint moves with the patient, preventing injury or dislocation of the shoulder.

It is actually incorrect; the restraint should be tied to the immobile base of the bed.

9. You have applied emergency restraints to Mr. Lavoie, who became violent due to a drug overdose. The situation is now under control. His parents arrive at the nursing station, demanding to know why their son is tied up.

Question:
What is your obligation regarding notification of the family/next of kin? *

You cannot disclose that he is restrained due to patient confidentiality.

You are required to notify the patient's representative (next of kin) as soon as possible after applying emergency restraints, explaining the reason and the plan.

You only need to tell them if the restraints are going to be on for more than 24 hours.

You should tell them it was a doctor's order and you had no choice.

10. Mrs. Cote, 79, is restrained in a chair with a waist belt. Suddenly, the fire alarm rings, and you see smoke coming from the adjacent room. You need to evacuate Mrs. Cote immediately.

Question:
This scenario highlights the importance of which safety feature of proper restraint application? *

The use of a quick-release (slip) knot or buckle that can be undone in seconds without cutting tools.

The use of a square knot to ensure the restraint does not slip.

Having a pair of scissors attached to the wall in every room.

Ensuring the restraint is loose enough to slide the patient out of it.

11. You are working in a long-term care facility. Mrs. Boisvert, an 80-year-old resident, spends her days in a wheelchair. To help her maintain "good posture" and eat her meals, the occupational therapist has installed a "lap tray" (table) that clips onto the wheelchair armrests. Mrs. Boisvert is physically unable to unclip the tray herself. She attempts to stand up to go to the bathroom but cannot move because the tray is blocking her.

Question:
How is this device classified in this specific situation? *

It is an adaptive positioning device, not a restraint, because it helps her posture.

It is a safety device because it prevents her from falling forward out of the chair.

It is an enabler because it assists her with eating.

It is a physical restraint because the patient cannot remove it herself and it restricts her freedom of movement.

12. Mr. Caron is a psychiatric patient admitted for acute psychosis. He becomes violent and threatens to kill the staff. Security intervenes, and he is placed in a "Seclusion Room" (a room with no furniture and a locked door) to de-escalate the situation.

Question:
Since Mr. Caron is not tied to a bed, does the "Protocol on Control Measures" apply? *

No, isolation is not a restraint; it is an environmental intervention.

Yes, seclusion (isolation) is classified as a control measure.

No, because he can still move his limbs freely within the room.

Yes, but only if he stays in there for more than 4 hours.

13. You are documenting the use of wrist restraints for Mr. Gagnon, who was pulling at his central line. You have documented the time applied, the type of restraint, and the patient's behavior.

Question:
What critical piece of information is missing from your documentation to legally justify the use of the restraint? *

The patient's blood type.

The name of the security guard who assisted.

The description of the less restrictive alternatives that were attempted and failed prior to applying the restraint.

The projected time the restraint will be removed.

14. A 5-year-old child is brought to the Emergency Department with a deep forehead laceration requiring sutures. The child is terrified, screaming, and thrashing. The physician asks you and the parent to hold the child's head and arms firmly still so he can suture the wound safely.

Question:
Is this action considered a "Restraint" requiring the full implementation of the Control Measures Protocol (forms, regular checks, debriefing)? *

Yes, because you are restricting the child's movement against his will.

Yes, because the child is screaming and clearly distressed.

No, this is temporary immobilization for a specific medical procedure, not a control measure for behavior management.

No, because the parent is the one consenting to the holding.

15. You are monitoring Mr. Rioux, who is in a vest restraint (Posey) in his bed. Upon entering the room, you notice that Mr. Rioux has slid down toward the foot of the bed. The vest is now bunched up around his chest and neck area.

Question:
What is the immediate risk in this scenario, and what is your priority action? *

Risk of pressure ulcers on the back; apply lotion.

Risk of compression asphyxia; reposition the patient and the vest immediately.

Risk of escape; tighten the straps to the bed frame.

Risk of agitation; administer a sedative.

16. The restraint on Mr. Ouellet's right wrist has been in place for 2 hours. According to standard nursing protocols, you enter the room to perform your scheduled care.

Question:
In addition to checking the skin and circulation, what specific action is required at this interval? *

Release the restraint completely to perform Range of Motion (ROM) exercises and offer toileting/hydration.

Rotate the restraint to the left wrist to give the right wrist a break.

Call the physician to renew the order.

Tighten the knot to ensure it hasn't loosened over the last 2 hours.

17. Security guards have just brought a violent patient, Mr. Talon, to the ground in the prone position (face down) to apply handcuffs and leg restraints. They leave him lying on his stomach on the stretcher to "keep him under control."

Question:
What is the critical safety intervention you must demand immediately? *

"We need to turn him onto his back or side immediately; leaving him face down can cause death."

"Make sure the handcuffs are double-locked so they don't tighten."

"Hold his head down firmly so he doesn't bite anyone."

"Administer an injection in his gluteus while he is in this position."

18. The acute episode of agitation has passed, and Mr. Lavoie has been calm for 2 hours. You have removed the restraints. The patient appears embarrassed and withdrawn.

Question:
What is the final, essential step in the restraint process that promotes psychological recovery? *

Documenting the removal time.

Warning the patient that if he acts up again, the restraints will go back on.

Transferring the patient to a different unit to a fresh start.

Conducting a debriefing session with the patient to discuss what happened, why the restraints were used, and how to prevent it in the future.

19. You are caring for a patient who requires "Constant Observation" (1:1 sitter) because the family refused physical restraints for their confused father. The family is paying for a sitter. You enter the room and see the sitter looking at her phone while the patient is trying to climb over the bedrails.

Question:
Who is legally responsible for the safety of the patient in this scenario? *

The sitter, because the family hired her specifically for this job.

The family, because they refused the restraints and assumed the risk.

The nurse, because delegation to a sitter does not remove the nurse's ultimate accountability for patient assessment and safety.

The hospital administration for not providing enough staff.

20. Mrs. Paquette is in the ICU and is extremely agitated. The decision is made to apply restraints. She is currently deemed incapacitated (unable to consent) due to her delirium. Her daughter (next of kin) is in the waiting room.

Question:
What is the obligation regarding consent in this emergency situation where immediate harm is threatened? *

You can apply the restraints immediately to prevent harm without consent, but you must inform the daughter as soon as possible afterward.

You must go to the waiting room and get the daughter's signature before applying the restraints.

You do not need to inform the daughter at all because it is a medical order.

You must wait until the patient calms down and consents herself.

21. You are working on a long-term care unit. Mrs. Dubé, an 85-year-old resident with cognitive impairment and a history of sliding out of her wheelchair, has just finished her lunch in the common dining room. The PAB (préposé aux bénéficiaires) wheels Mrs. Dubé back to her room near the nursing station. The PAB leaves the "locking table" (lap tray) attached to the wheelchair and tells you, "I’m going to leave the table on for the afternoon. Even though she finished eating, it keeps her in a good upright position so she doesn't slide down and fall. Plus, I have to go help with baths."

Question:
What is your priority nursing intervention in response to the PAB’s action? *

Thank the PAB for being proactive about the patient's posture and fall risk.

Document the use of the table as a safety device in the patient's file.

Ask the PAB to put a pillow behind the patient's back to make her more comfortable while the table is on.

Go to the patient immediately and assess if she is physically able to remove the table herself; if she cannot, remove it.

22. Mr. Gagnon, a patient with dementia, became physically aggressive earlier this morning and struck a PAB. Due to the imminent danger, emergency wrist restraints were applied. It is now 2 hours later. You enter the room and find Mr. Gagnon sleeping calmly and deeply. His daughter is sitting at the bedside. She looks at you and asks, "He has been asleep for an hour and seems very peaceful now. Is it okay to take those things off his wrists? They look uncomfortable."

Question:
According to the legal standards for the use of control measures, what is the appropriate action? *

Explain to the daughter that the restraints must stay on for a minimum of 2 hours to ensure the aggression has completely passed.

Wake the patient up to assess his mental status; if he is aggressive, keep them on.

Remove the restraints immediately while he is sleeping, as the behavior necessitating them is no longer present.

Loosen the restraints slightly but keep them secured until the physician rounds later in the day.

23. You arrive for your shift on a medical unit that is severely short-staffed today. You notice that the door to Mr. Tremblay’s room is closed and locked from the outside. Mr. Tremblay has Alzheimer’s disease and is known to wander the corridors, often entering other patients' rooms. Your colleague tells you, "I locked him in there for now. We are short two nurses, and I simply cannot chase him around the unit all day while trying to pass medications. It’s for his own safety so he doesn't get lost."

Question:
What is your ethical and clinical judgment regarding this intervention? *

It is an acceptable temporary safety measure given the staffing crisis.

It is appropriate, but the colleague must check on him every 15 minutes and document it as "Seclusion."

It is only acceptable if the family has given permission for him to be locked in.

It is a violation of the patient's rights; unlock the door immediately and attempt alternative diversion strategies.

24. You are working on a psychiatric unit. You enter the room of a newly admitted patient, Ms. Lavoie, to introduce yourself. You notice she is standing by the window holding a plastic serrated knife from her lunch tray. She is gripping it tightly, but she is not lunging at you or making verbal threats. She looks frightened.

Question:
To ensure personal safety and de-escalate the situation, what is your first intervention? *

Immediately trigger the "Code White" (Violence/Aggression) alarm and run out of the room.

Walk rapidly toward her and grab her wrist to remove the weapon before she can use it.

Stop moving, maintain a safe distance (beyond striking range), keep your hands visible, and speak in a calm, low voice.

Shout at her to drop the knife immediately to show authority.

25. You are working in the Emergency Department triage area. A 30-year-old male patient, Mr. Roy, walks in pacing rapidly and muttering to himself. As you approach the glass partition to speak to him, he suddenly pulls a large metal hunting knife from his jacket pocket and starts waving it in the air, yelling, "Don't come near me! I won't let you take me!" He is blocking the exit to the waiting room where other patients are sitting.

Question:
What is your absolute first priority intervention? *

Attempt to de-escalate the patient by speaking calmly and asking him to put the knife down.

Immediately evacuate the other patients from the waiting room to a secure area.

Activate the "Code White" (Violence) alarm and call 911 (Police) immediately.

Lock yourself in the triage booth and document the patient's behavior.

26. Mr. Ouellet, an older adult with advanced Alzheimer’s disease, is in the hallway. He is banging his fists aggressively against the locked door of the common bathroom and shouting incomprehensibly. He appears red-faced and agitated. Other patients are becoming frightened.

Question:
What is the most appropriate intervention? *

Administer a PRN dose of Haloperidol immediately to control his aggression.

Escort him to his room and apply restraints to prevent injury to himself or the door.

Approach him calmly from the side, validate his frustration, and ask if he needs to use the toilet.

Call security to remove him from the hallway.

27. You are working in the psychiatric emergency department. Mr. Larocque, a 28-year-old patient admitted for acute psychosis, has become increasingly aggressive. He is throwing chairs and threatening to "smash everyone." Verbal de-escalation techniques have failed. The psychiatrist arrives and writes two orders simultaneously: "Apply 4-point mechanical restraints" and "Administer Haloperidol 5 mg + Lorazepam 2 mg IM immediately."

Question:
According to the protocol on control measures and the principle of the least restrictive means, how should you prioritize these interventions? *

Apply the mechanical restraints and keep them on for at least 4 hours, regardless of the medication's effect.

Prioritize the administration of the medication to treat the underlying agitation; use the mechanical restraints only as a temporary measure to safely administer the injection and wait for it to take effect.

Withhold the medication and use only the mechanical restraints to avoid over-sedating the patient.

Ask the patient to choose which method he prefers to give him a sense of control.

28. You are the primary nurse for Mr. Gagnon, a large male patient who is currently experiencing a manic episode with aggressive features. He is pacing his room, clenching his fists, and shouting at unseen stimuli. You have successfully prepared a PRN syringe of Haloperidol (Haldol) 5 mg IM to help de-escalate his agitation. You are ready to enter the room to administer the medication.

Question:
What is your priority action before opening the door? *

Hide the syringe behind your back so the patient does not see it and become provoked.

Enter the room quickly to catch the patient by surprise before he can react.

Announce loudly from the doorway, "Mr. Gagnon, I have your medication, please lie down."

Request immediate assistance from security agents or colleagues (Code White team) to accompany you into the room.

29. Mr. Tremblay was placed in 4-point mechanical restraints (both wrists and both ankles) two hours ago due to severe aggressive behavior. Upon your current assessment, he is calm, cooperative, and oriented. He asks, "Can you please untie me now? I promise I'm okay." You determine that it is safe to begin removing the restraints.

Question:
What is the correct sequence for removing the restraints? *

Remove both wrist restraints simultaneously to allow the patient to sit up and drink water.

Remove one wrist restraint first and observe the patient's behavior before removing the others.

Remove one ankle restraint first to see if he attempts to kick.

Remove all four points immediately since the risk is no longer present.