Question

An older adult client is in physical restraints. Which intervention by the nurse is the priority?

A Assess the client hourly while keeping the restraints in place.
B. Assess the client once each shift, releasing the restraints for feeding.
C. Assess the client twice each shift while keeping the restraints in place.
D. Assess the client every 30 to 60 minutes, releasing restraints every 2 hours.

Answer 1

The priority intervention is to assess the client every 30 to 60 minutes and release the restraints every 2 hours to monitor their condition and ensure comfort.

Step-by-step explanation:

The priority intervention for an older adult client in physical restraints is to assess the client every 30 to 60 minutes while releasing the restraints every 2 hours. This ensures that the client's physical condition and comfort are regularly monitored and allows for relief of pressure and repositioning to prevent complications such as skin breakdown and decreased circulation.