A confused client repeatedly reaches for a nasogastric tube, and wrist restraints are prescribed after less restrictive measures fail. For each group, select all responses that apply.

Before restraint use, assess unmet needs, document attempted alternatives, and verify the current order and limits. Sedation is not a substitute for restraint assessment, and family consent does not replace the authorized order and facility process. During use, perform and document frequent skin, circulation, sensation, range-of-motion, behavior, and continued-need assessments. Never secure a restraint to a side rail or remove access to the call system.

Use only the findings, timing, and orders stated in the scenario.

Apply the requested nursing decision to this client rather than relying on a broad disease label.

The remaining responses are contradicted by the scenario, mistimed, outside scope, or unsafe.

Address immediate threats first and reassess after intervention.

Choose only actions supported at this exact point in care.

• restraints — restraints is a key clinical concept for assessing and managing restraint safety.
• neurovascular assessment — neurovascular assessment is a key clinical concept for assessing and managing restraint safety.
• range-of-motion — range-of-motion is a key clinical concept for assessing and managing restraint safety.