Safety and Emergency Care · NCLEX Exam

A restrained patient begins to thrash and remove restraints despite quiet instructions. What is the nurse’s responsibility?

  1. Continue the restraints indefinitely until the patient stops thrashing
  2. Release the restraints, supervise and assess the cause of agitation
  3. Ignore the behavior and wait for the patient to calm down on their own
  4. Increase the sedation dosage without first consulting the provider
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Correct answer: Release the restraints, supervise and assess the cause of agitation

Safety/emergency: Restraints must be monitored, reassessed, released when possible, agitation cause assessed to prevent harm.

Difficulty: Medium Question 15 of 20

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