247SimpleTests
NCLEX · Crisis and Grief

A nurse calls security after a client with paranoid schizophrenia becomes increasingly agitated and is threatening to hit staff. After de-escalation fails, the client must be physically restrained. What is the nurse's priority during the restraint process?

Correct answer

Protect the client's airway and monitor vital signs during and immediately after the restraint — physical restraint carries risk of positional asphyxia (particularly prone restraint), excited delirium, and cardiac events; monitor breathing and oxygenation continuously

  1. A Ensure the most staff are involved to look authoritative
  2. B Protect the client's airway and monitor vital signs during and immediately after the restraint — physical restraint carries risk of positional asphyxia (particularly prone restraint), excited delirium, and cardiac events; monitor breathing and oxygenation continuously
  3. C Document first, then assist
  4. D Focus only on protecting staff

Why this is the answer

SAFETY DURING PHYSICAL RESTRAINT: RESTRAINT RISKS: POSITIONAL ASPHYXIA: If face-down (prone) restraint is used, chest compression restricts breathing; risk of death; EXCITED DELIRIUM: State of extreme agitation with high sympathetic drive; risk of sudden cardiac death during or after restraint; MONITORING DURING RESTRAINT: Airway — ensure unobstructed airway at all times; respiratory status — observe chest rise, SpO2 if possible; level of consciousness; CRITICAL: The period immediately after restraint is a high-risk time — the individual may become suddenly unresponsive after fighting against restraint stops (cardiovascular collapse); BEST PRACTICE: Avoid prone restraint; allow the individual to be in a position that permits adequate breathing; at least one staff member monitors vital signs and consciousness throughout; DEBRIEF: After the event: assess for injuries to client and staff; document; psychological debrief for staff; determine if there were missed early warning signs; LEAST RESTRICTIVE: Physical restraint is the most restrictive option and should be followed immediately by verbal de-escalation attempts once the immediate danger is controlled.
Source: NCLEX-RN Psychosocial — Crisis Intervention, Restraint Safety

Practice more questions

This question is from our NCLEX Practice Tests practice test. Take the full practice test to test your knowledge across all Crisis and Grief and other topics.

Take the RN: Psychosocial Integrity practice test →

New to this exam? Our NCLEX exam guide explains the format, scoring, and how to prepare.

Related questions

Crisis and Grief

What are the five stages of grief described by Elisabeth Kübler-Ross?

 Crisis and Grief

What is a 'crisis' in mental health, and what are the key principles of crisis intervention?

 Crisis and Grief

A nurse following the crisis intervention model responds to a client who reports their spouse just left them and they feel there is no reason to live. Which approach is CORRECT?

 Crisis and Grief

A client comes to the emergency department after disclosing suicidal ideation to a friend. The nurse's FIRST priority is:

State-specific guides

Need information for your state? Our state guides cover local requirements, fees, and what to expect on exam day.

California Texas Florida New York Pennsylvania Illinois Ohio Georgia

Recommended study materials

Study guide

Saunders Comprehensive Review for NCLEX-RN 9th Ed. (Elsevier)

The gold standard for NCLEX-RN prep: 5,200+ practice questions, content review, test-taking strategy.

Check Price → Study guide

NCLEX-PN Prep Plus 2023 (Kaplan)

Targeted NCLEX-PN content review with hundreds of practice questions and video explanations.

Check Price → Study guide

Prioritization, Delegation & Assignment (Elsevier)

The leading resource for NCLEX questions on prioritization, delegation, and management of care.

Check Price →

As an Amazon Associate, CJ Affiliate, and AWIN publisher we earn from qualifying purchases. Links above are affiliate links. Full disclosure →