A restrained patient said to the nurse that his behaviour is under control and now you can remove the restraints. What is the most appropriate nursing action?

Appeared in: AIIMS Delhi NO-2016

Explanation

The correct action is to remove one restraint at a time, typically starting with one hand.
This method serves as a 'trial release,' allowing the nurse to safely assess if the patient can maintain behavioral control.
It is a graded approach that balances patient autonomy with the safety of the patient and staff.
If the patient remains calm, the nurse can proceed with further removal; if agitation occurs, the limb can be easily re-secured.
This action aligns with the principle of using the least restrictive means necessary for the shortest duration possible.

Option A: Removing all restraints simultaneously is a major safety risk. If the patient is not truly in control, they could immediately become violent, harming themselves or others.
Option C: This action abdicates the nurse's responsibility to perform ongoing assessments. The nurse's scope of practice includes evaluating the patient's readiness for restraint removal.
Option D: This is a passive and negligent response. The nurse has a duty to assess the patient's condition, respond to their communication, and evaluate the continued need for restraints.

Clinical Relevance

Nursing practice connection: Use the key finding related to Nursing management and safe discontinuation of physical restraints to guide bedside assessment, documentation, and the next nursing action.
The use of restraints is a significant intervention with legal and ethical implications. Nurses must balance patient safety with the patient's right to be free from restraint.
Improper management or prolonged use of restraints can lead to complications like pressure injuries, nerve damage, psychological distress, and even death.
Thorough and timely documentation is critical. It must include the failure of less restrictive alternatives, the specific reason for the restraint, and all assessments and care provided during the restraint period.

How to Approach the Question

First, identify the core clinical problem: a patient is requesting the removal of physical restraints.
Next, analyze the question's focus: it asks for the 'most appropriate' nursing action, which implies a judgment based on safety and standard protocols.
Evaluate each option against the primary principle of patient and staff safety. This is the highest priority in restraint management.
Eliminate option A ('Remove patient's restraint') because removing all restraints at once is inherently unsafe and high-risk.
Eliminate option D ('Don't do anything') as it represents inaction and negligence, which is never a correct nursing response.
Differentiate between option B ('Remove restraints from one hand') and option C ('Wait for doctors to come'). Option B is an active assessment step that falls within the nurse's role, while option C is passive and defers a key nursing responsibility.

Concept Tested & Keywords

Concept Tested: Nursing management and safe discontinuation of physical restraints.
Stem keywords: restrained patient, behaviour is under control, remove the restraints, nursing action
Lead-in keywords: most appropriate

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E6 Nursing Fundamentals Taylor pp. 286-288, 273-275

E6 Nursing Fundamentals Potter Perry 12e Part 2 p. 207-209

Practise the full AIIMS Delhi NO-2016

Attempt every question from this paper in a timed mock, then review the full solution for each one.