The Nurse Is Caring for a Patient in Restraints

question 2

Multiple Choice

The nurse is caring for a patient in restraints.Which of the following pieces of information about restraints must be documented by the nurse in the medical record? (Select all that apply. )

• A)The patient states that her gown is soiled and needs changing.
• B)Previous attempts to distract the patient with television were unsuccessful.
• C)The patient was placed in bilateral wrist restraints at 0815.
• D)One family member has gone to lunch.
• E)Bilateral radial pulses present,2+,hands warm to touch.
• F)Released from restraints,active range-of-motion exercises complete.

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