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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?

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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 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
  2. B Ensure the most staff are involved to look authoritative
  3. C Focus only on protecting staff
  4. D Document first, then assist

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

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About this topic: Crisis and Grief

Crisis and grief questions cover crisis theory and intervention, suicide risk assessment and precautions, violence de-escalation, and supporting clients and families through loss. This is one of 9 RN: Psychosocial Integrity questions on crisis and grief, each with a full explanation on a single study page.

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

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