Which statement is correct regarding the use of restraints?

• A. Use restraints only with an order and as a last resort
• B. Reassess every 4 hours
• C. Release and reassess only after 8 hours
• D. Documentation is optional

Answer: (A)

Restraints are a last-resort measure and must be used only when there is a documented order from a clinician. This protects the patient’s rights and safety, ensuring that any restriction of movement is medically justified and monitored. Before resorting to restraints, you should try the least restrictive alternatives first—like de-escalation, calm communication, reducing stimuli, or increased one-to-one observation. If restraints are used, they should be in place for the shortest time necessary and with continuous monitoring of the patient’s safety, circulation, skin integrity, comfort, and overall condition. Documentation is essential, recording the justification, type of restraint, placement, checks, and the plan for reassessment and removal.