Hazards of restraints are?

KPSC Staff Nurse - 2017

Nursing Foundation

Easy

Appeared in: KPSC Staff Nurse - 2017

Explanation

The use of physical restraints leads to immobility and sustained pressure on various body parts, which can cause a cascade of complications.
Nerve damage occurs from direct compression of nerves by the restraint device.
Pressure sores (pressure injuries) develop from prolonged ischemia in tissues overlying bony prominences.
Foot drop is a specific type of contracture and nerve injury resulting from the foot being held in plantar flexion and pressure on the peroneal nerve.
Since all the listed conditions are recognized hazards, the most comprehensive and correct answer is 'All of the above'.

Option A: While nerve damage is a correct hazard of restraints, it is not the only one listed. The option 'All of the above' is more comprehensive.
Option B: While pressure sores are a correct hazard of restraints, they are not the only one. The option 'All of the above' is more comprehensive.
Option C: While foot drop is a correct hazard of restraints, it is not the only one. The option 'All of the above' is more comprehensive.

Clinical Relevance

Nursing practice connection: This is primarily an exam-oriented knowledge point with limited direct bedside application, so retain Complications and hazards associated with the use of physical restraints in patient care as background academic context rather than a clinical decision trigger.
Restraints are a high-risk intervention and should only be used as a last resort when a patient is a danger to themselves or others, and a provider's order is required.
Nurses have a critical responsibility to perform and document frequent neurovascular and skin integrity checks (typically every 1-2 hours) to prevent these complications.
What if? If a restrained patient becomes more agitated, the nurse's first action should be to assess for an underlying cause (e.g., pain, hypoxia, need for toileting, fear) rather than assuming the need for more restraint. Addressing the root cause often resolves the agitation.

How to Approach the Question

First, identify the core concept of the question, which is the 'hazards' or negative consequences of using 'restraints'.
Evaluate each of the initial options (A, B, and C) based on your nursing knowledge.
Determine if 'Nerve damage' is a plausible hazard. Yes, pressure from straps can compress nerves.
Determine if 'Pressure sore' is a plausible hazard. Yes, immobility and pressure cause skin breakdown.
Determine if 'Foot drop' is a plausible hazard. Yes, prolonged immobility and nerve pressure can cause this contracture.
Since you have identified that options A, B, and C are all correct, look for an option that encompasses all of them. In this case, 'All of the above' is the most complete and therefore the best answer.

Concept Tested & Keywords

Concept Tested: Complications and hazards associated with the use of physical restraints in patient care.
Stem keywords: Hazards, restraints
Lead-in keywords: are
Negative lead-in flag: false

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E6 Nursing Fundamentals Potter Perry 12e Part 4 p. 132-134

E6 Nursing Brunner Adult Health 3SA Vol 1 Part 4 p. 127-129