The Nurse Is Preparing to Write the Nursing Progress Notes

question 18

Multiple Choice

The nurse is preparing to write the nursing progress notes for a patient who has wrist restraints. Which chart entries will the nurse include in the progress notes? Select all that apply.

• A)Family teaching initiated regarding the need for patient restraint
• B)Restraint removed once per shift to assess skin color, sensation, and movement of extremity
• C)Prescription for wrist restraint received from the primary care provider
• D)Wrist restraints applied because of the patient's increasing confusion
• E)Double knot used to tie restraints to bed frame

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