# Complete the safety statements for restraint use in a psychiatric patient. > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=393391&lang=en > language: en > subject: Use of Restraints/Safety Devices > category: SIPC ## Question Complete the safety statements for restraint use in a psychiatric patient. Restraints are used only when ::선택::less restrictive measures have failed and there is imminent risk of harmthe family requests it for safetythe unit is short-staffedthe patient refuses oral medication. The maximum initial order duration for an adult behavioral restraint is ::선택::1 hour2 hours4 hours24 hours. An in-person face-to-face evaluation must occur within ::선택::1 hour4 hoursthe next shiftmorning rounds of restraint initiation. Under the stated facility policy, the nurse documents circulation, hydration, and continued need every ::선택::1 hour15 minutes30 minutesevery shift. ## Explanation The adult order limit is 4 hours, not 2 hours. For violent or self-destructive restraint, the maximum order duration is 4 hours for adults, 2 hours for ages 9 through 17, and 1 hour for children under 9; the client must receive a face-to-face evaluation within 1 hour. CMS requires monitoring at an interval set by hospital policy, so the 15-minute answer applies because this scenario states that facility policy. Restraint must end as soon as the immediate safety threat resolves. ## In-depth explanation Correct Answer The adult behavioral-restraint order is limited to 4 hours, the face-to-face evaluation occurs within 1 hour, and this facility documents monitoring every 15 minutes. Why It Fits Restraint is permitted only for an immediate physical-safety threat after less restrictive measures fail, and it must stop at the earliest safe time. Clinical Picture Think of the order limit and the bedside monitoring interval as two separate clocks: federal rules cap the order duration, while the stated hospital policy supplies the 15-minute documentation interval. Memory Link Adult 4 hours; ages 9–17, 2 hours; under 9, 1 hour; face-to-face within 1 hour. NCLEX Rule Choose the least restrictive action, verify a time-limited order, monitor safety needs, and discontinue restraint as soon as the danger resolves. Never use restraint for convenience, discipline, coercion, or staffing problems. Why the Alternatives Fail Family request, medication refusal, or short staffing does not establish an immediate safety threat. A 2-hour adult order is the adolescent limit, and a universal federal 15-minute rule should not be inferred without the facility-policy cue. Source 142 CFR §482.13, Patient's rights ## Clinical scenario Adult inpatient with imminent risk of self-harm and physical aggression after de-escalation failed. The facility policy requires documentation every 15 minutes while the restraint is in use. ## Key concepts - **least restrictive** — Principle requiring use of the minimum intervention needed to prevent harm. - **in-person evaluation** — Face-to-face provider assessment required within 1 hour of behavioral restraint initiation. - **debriefing** — Post-event review with patient and staff to identify triggers and prevent recurrence. ## Related questions - [An older adult who is confused after surgery repeatedly tries to pull at an IV line. Which…](https://mymerci.kr/pages/nclex_q.php?qn_id=393833&lang=en) - [The nurse assesses a client in a soft wrist restraint. Click the unsafe point of restraint…](https://mymerci.kr/pages/nclex_q.php?qn_id=499740&lang=en) - [A confused client is in prescribed wrist restraints that were applied after less restricti…](https://mymerci.kr/pages/nclex_q.php?qn_id=522684&lang=en) - [A confused client repeatedly reaches for a nasogastric tube, and wrist restraints are pres…](https://mymerci.kr/pages/nclex_q.php?qn_id=620053&lang=en) - [A nurse discovers a small fire in a client's room. Place the following actions in the corr…](https://mymerci.kr/pages/nclex_q.php?qn_id=620068&lang=en) - [A nurse is caring for a client who begins to have a generalized tonic-clonic seizure. Plac…](https://mymerci.kr/pages/nclex_q.php?qn_id=620069&lang=en) ## Read in another language - [en](https://mymerci.kr/pages/nclex_q.php?qn_id=393391&lang=en) - [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=393391&lang=ko) - [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=393391&lang=ja) - [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=393391&lang=zh-tw) - [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=393391&lang=vi) --- More free questions: [NCLEX-RN Practice](https://mymerci.kr/pages/nclex_bank.php?lang=en) _For study reference only. Always follow current clinical guidelines and your institution’s protocols._