A nurse is collecting data from a client who has a wrist restraint in place. Which of the following findings should the nurse identify as an indication of a complication of the restraint?

The client has full range of motion in her wrist.

The client is attempting to remove the restraint.

The client's hand is cool and pale.

The client has a capillary refill of 1 second.

Answer and Explanation

The Correct Answer is C

Choice A reason: Full range of motion indicates that circulation and mobility are intact. This is not a complication.

Choice B reason: Attempting to remove the restraint shows discomfort or resistance but does not indicate a complication.

Choice C reason: A cool, pale hand suggests impaired circulation due to the restraint. This is a serious complication that requires immediate intervention to prevent tissue damage.

Choice D reason: A capillary refill of 1 second is normal and indicates adequate perfusion. This is not a complication.

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Correct Answer is B

Explanation

Choice A reason: Encouraging the client to argue with voices reinforces the hallucination and is not therapeutic.

Choice B reason: Telling the client the hallucination is not real helps orient them to reality while maintaining empathy. It acknowledges their experience without validating the hallucination.

Choice C reason: Acting as if the hallucination is real reinforces psychosis and is inappropriate.

Choice D reason: Asking direct questions about the hallucination can increase focus on the false perception, worsening symptoms.

A. Allow the client to interact freely with others on the unit. B. Inform the client that restraints may be necessary if she cannot control her behavior. C. Escort the client to her room when she is observed trying to interact with other clients. D. Assist the client to practice social interaction with peers during a community meeting.

Correct Answer is C

Explanation

Choice A reason: Allowing free interaction worsens disruption and does not protect other clients’ rights to a therapeutic environment.

Choice B reason: Threatening restraints is inappropriate and escalates agitation. Restraints are only used as a last resort for safety, not for excessive talking.

Choice C reason: Escorting the client to her room removes her from the disruptive environment and provides a calmer space. This is the most appropriate intervention to manage manic behavior.

Choice D reason: Practicing social interaction is useful in stable phases, but during acute mania the client cannot control excessive talking. This is not appropriate at this time.

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A nurse is collecting data from a client who has a wrist restraint in place. Which of the following findings should the nurse identify as an indication of a complication of the restraint?

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