# Situation: A 45-year-old woman with bipolar I disorder, current episode manic, is on the acute psychiatric ward. Nurses write their notes in focus charting, and the treatment team writes problem-oriented progress notes in SOAPIE format (Subjective, Objective, Assessment, Plan, Intervention, Evaluation). Restraint, when used, is recorded on a separate observation sheet. At 14:40 she strikes a staff member. Per unit protocol, a client in restraint is observed continuously; checks are recorded every 15 minutes; fluids and toileting are offered at least every 2 hours and whenever the client asks; and every action taken is recorded. The observation sheet reads: 14:40 Struck staff member; verbal de-escalation and quiet room offered, refused 14:45 Four-point limb restraint applied on order of attending psychiatrist 15:00 Limbs warm, pink, pulses present; breathing 18 per minute, even; shouting 15:15 Limbs warm, pink, pulses present; breathing 18 per minute, even; shouting 15:30 Limbs warm, pink, pulses present; breathing 16 per minute; quiet, asks for water 15:45 Limbs warm, pink, pulses present; breathing 16 per minute; calm, answers questions 16:00 Limbs warm, pink, pulses present; breathing 16 per minute; calm 16:15 Calm 30 minutes, no threats; release criteria met; restraint removed Which element required by the protocol is missing from the record?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630055  
> language: ko  
> subject: Nursing Practice V — Care of Clients with Maladaptive Patterns of Behavior; Care of Clients with Life-Threatening Conditions, Acute Multi-Organ Problems, High Acuity and Emergency Situations

## 문제

Situation: A 45-year-old woman with bipolar I disorder, current episode manic, is on the acute psychiatric ward. Nurses write their notes in focus charting, and the treatment team writes problem-oriented progress notes in SOAPIE format (Subjective, Objective, Assessment, Plan, Intervention, Evaluation). Restraint, when used, is recorded on a separate observation sheet.

At 14:40 she strikes a staff member. Per unit protocol, a client in restraint is observed continuously; checks are recorded every 15 minutes; fluids and toileting are offered at least every 2 hours and whenever the client asks; and every action taken is recorded. The observation sheet reads:
14:40 Struck staff member; verbal de-escalation and quiet room offered, refused
14:45 Four-point limb restraint applied on order of attending psychiatrist
15:00 Limbs warm, pink, pulses present; breathing 18 per minute, even; shouting
15:15 Limbs warm, pink, pulses present; breathing 18 per minute, even; shouting
15:30 Limbs warm, pink, pulses present; breathing 16 per minute; quiet, asks for water
15:45 Limbs warm, pink, pulses present; breathing 16 per minute; calm, answers questions
16:00 Limbs warm, pink, pulses present; breathing 16 per minute; calm
16:15 Calm 30 minutes, no threats; release criteria met; restraint removed
Which element required by the protocol is missing from the record?

## 보기

1. A response to her 15:30 request for water **✔ 정답**
2. The less restrictive measures tried first
3. An offer of toileting during the restraint
4. The behavior showing release criteria were met

**정답: 1**

## 해설

The record shows alternatives tried, the order, 15-minute checks of circulation and breathing, and the behavior that met release criteria. At 15:30 she asked for water, and the protocol requires fluids whenever the client asks and every action to be recorded, yet no entry shows a drink was offered. Toileting was not yet due because the restraint lasted only 1.5 hours (14:45 to 16:15) and she did not ask.

## 심화 해설

What the record already shows

The observation sheet documents that verbal de-escalation and a quiet room were offered and refused before restraint was applied, the attending psychiatrist’s order at 14:45, continuous circulation and breathing checks every 15 minutes, and the behavioral change—calm for 30 minutes with no threats—that met release criteria at 16:15. These entries satisfy the protocol’s requirements for less restrictive alternatives, ordered application, monitoring frequency, and documented release.

The missing element

At 15:30 the client asked for water. The unit protocol states that fluids are offered whenever the client asks, and that every action taken is recorded. The observation sheet contains no entry indicating that water was provided or that the request was addressed. This is a documentation omission that directly violates the protocol’s fluid-offer and action-recording requirements.

The absence of any note responding to the 15:30 request for water is the only protocol element missing from the record.

Why toileting is not the correct answer

The protocol requires toileting offers at least every 2 hours and whenever the client asks. Restraint began at 14:45 and ended at 16:15—a total duration of 1.5 hours. The client did not request toileting during this period. Therefore, the 2-hour scheduled toileting offer was not yet due, and no protocol violation occurred regarding toileting.

Why the other options are already satisfied

Less restrictive measures were documented at 14:40—verbal de-escalation and quiet room were offered and refused. The behavior showing release criteria were met is recorded at 16:15: calm for 30 minutes, no threats. These entries are complete and consistent with the protocol.

Clinical reasoning for nursing documentation

In restraint situations, documentation serves both clinical and legal functions: it demonstrates that the client’s physical safety was monitored and that basic needs—hydration, elimination, comfort—were addressed. A request for water during restraint is a direct expression of a basic physiological need. Failing to record the response creates ambiguity about whether the need was met, which can be interpreted as neglect in review or litigation.

Key point! When a client in restraints makes any request, the nurse’s response—whether the request was granted, deferred with rationale, or refused by the client—must be documented immediately. Silence in the record is treated as no action taken.

Watch out! Do not confuse scheduled toileting intervals with as-needed fluid requests. The former follows a time-based rule (every 2 hours); the latter is triggered by the client’s verbal request and requires an immediate documented response regardless of timing.

Broader context from restraint research

Systematic review evidence on physical restraints in psychiatric settings highlights that nursing documentation and adherence to monitoring protocols are central to patient safety and ethical practice . The review notes that restraint use raises significant concerns regarding patient dignity and therapeutic impact, and that consistent, accurate recording of care activities—including responses to basic needs—is part of accountable nursing practice . When a client is restrained, the nurse’s documentation becomes the primary evidence that humane care was delivered throughout the episode.

The omission of the response to the 15:30 water request is significant because it creates a gap in the record where the protocol explicitly required both an action and its documentation.

## 임상 시나리오

Restraint Documentation ProtocolComplete every required element in the observation record
When a patient is in restraint, document continuous observation, 15-minute circulation and breathing checks, and every action taken. If the patient requests fluids, the offer and response must be recorded immediately.

A missing entry for a patient request is a documentation omission and a protocol violation, even if all other elements are present. Always close the loop: note the request, the action, and the patient's response.

CautionDo not assume an unrecorded action occurred. In legal and quality reviews, undocumented equals not done. Toileting offers follow the 2-hour schedule or patient request, whichever comes first.

## 핵심 개념

- **Focus charting** — A documentation method using a columnar format to record patient-focused data, actions, and responses.
- **SOAPIE** — Problem-oriented progress note format: Subjective, Objective, Assessment, Plan, Intervention, Evaluation.
- **Four-point restraint** — Restraining all four limbs to immobilize a patient for safety during acute behavioral emergencies.
- **Release criteria** — Predetermined behavioral standards that must be met before a restraint can be safely removed.

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