07FC Skills Video

Applying Restraints

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ALERT
 Because of the association with fatal injuries, many health care organizations now prohibit the use of jacket
(vest) restraints.
 Limit the use of restraints when physically possible. Use and type of restraint must be based on a thorough
assessment of the patient when other therapies have been ineffective.
 Place the patient in the lateral position, or elevate the head of the bed. The patient with extremity restraints is
at risk for aspiration if placed in the supine position.
 Use a quick release tie to secure the restraint.
 Ensure that the restraint does not interfere with equipment, such as an IV, and is not placed over an access
device, such as an arteriovenous shunt.
 Do not attach the straps of a restraint to the side rails of the bed.
 Do not tie the straps of a restraint into a knot.
 Check the skin under the restraint for abrasions.
 Change wet or soiled restraints to prevent skin breakdown.
 Remove a restraint immediately if the patient has an alteration in neurovascular status of an extremity, such
as cyanosis, pallor, or coldness of the skin, or if the patient complains of tingling, pain, or numbness in the
restrained extremity.
1. Gather the necessary equipment and supplies.
2. Perform hand hygiene.
3. Provide for the patient’s privacy.
4. Use a calm approach and introduce yourself to the patient, including both name and title or role.
5. Verify health care provider’s orders. Determine if signed consent is necessary.
6. Identify the patient using two identifiers, such as the patient’s name and birth date or the patient’s name and
account number.
7. Explain the procedure to the patient and ensure that he or she agrees to treatment. Consult with practitioner for
non-compliant patients and confirm orders before proceeding.
8. Adjust the bed to the proper height, and lower the rail closest to you. Be sure that the patient is comfortable and
in the correct anatomical position.
9. Inspect the area to which the restraint will be applied. Note any tubes or devices. Assess the patient’s skin
integrity, sensation, circulation, and range of motion.
10. Pad the patient’s skin and bony prominences that will be covered by the restraint as necessary.
11. Apply the proper size restraint, and follow the manufacturer’s instructions for use.
a. Belt restraint: Help the patient into a sitting position. Apply the belt over the patient's clothes, hospital
gown, or pajamas. Smooth out wrinkles or creases in the patient’s clothing. Be sure to place the restraint
at the waist, not the chest or the abdomen. Bring the ties through the slots in the belt. Avoid applying
the belt too tightly. Assist the patient to a supine position if he or she is in bed. Ask the patient to take a
deep breath to ensure there is no restriction to breathing. Attach the restraint securely to a stationary
part of the bed frame.
b. Extremity (ankle or wrist) restraint: Commercially available limb restraints are made of sheepskin or
foam padding. Wrap the limb restraint around the patient’s wrist or ankle, with the soft part toward the
patient’s skin, and secure it snugly, but not tightly, by using the Velcro straps or clips. Check to make sure
 the restraint is not too tight by inserting one finger under the secured restraint. Secure the strap through
the D-ring. Use a quick release tie to secure the restraint to the stationary part of the bed frame.
c. Mitt restraint: A thumbless hand mitt device is used to restrain a patient’s hands. Place the patient’s
hand in the mitt, making sure that the Velcro strap(s) are around the patient’s wrist, and not the
forearm. Check to see that one finger slides easily beneath the restraint.
d. Elbow restraint: This device is a rigid, padded, fabric splint that immobilizes the elbow joint. It can be
removed by the patient. This will help the patient stop picking at an IV line. Place restraint around the
patient’s arm so the elbow joint rests against the padded area. Keeping the elbow rigid, secure splint
with Velcro straps. Check fit of restraint. Hook clip to upper end of sleeve of patient’s gown.
12. Reminder: Attach the restraint straps to the stationary part of the bed frame. Be sure the straps are secure. Do
not attach the straps to the side rails. Restraints can be attached to the frame of a chair or a wheelchair as long
as the ties are out of the patient’s reach.
13. Secure the restraints with a quick-release tie, a buckle, or an adjustable seat belt-like locking device. Do not tie
the straps of the restraint into a knot.
14. Double-check to make sure you can insert one finger under any secured restraint.
15. Remove the restraints at least every 2 hours or according to your organization’s policy for time specifications for
restraint removal, and assess the patient each time. Assess the proper placement of the restraint, including the
patient’s skin integrity, pulses, temperature, color, and sensation of the restrained body part. If the patient is
violent or noncompliant, remove one restraint at a time, and/or have other health care team members assist you
as you remove the restraints.
16. To ensure the patient's safety, secure the call light or intercom system within reach and lock the wheels on the
patient’s bed or chair. Keep the bed in the lowest position, and raise the appropriate number of side rails.
17. Dispose of used supplies and equipment. Leave the patient's room tidy.
18. Remove and dispose of gloves, if used. Perform hand hygiene.
19. Document and report the patient’s response and expected or unexpected outcomes. Document the type of
restraint, time applied, and reason for restraint.

Extended Text
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ALERT
 Because of the association with fatal injuries, many health care organizations now prohibit the use of jacket
(vest) restraints.
  Limit the use of restraints when physically possible. Use and type of restraint must be based on a thorough
assessment of the patient when other therapies have been ineffective.
 Place the patient in the lateral position, or elevate the head of the bed. The patient with extremity restraints is
at risk for aspiration if placed in the supine position.
 Use a quick release tie to secure the restraint.
 Ensure that the restraint does not interfere with equipment, such as an IV, and is not placed over an access
device, such as an arteriovenous shunt.
 Do not attach the straps of a restraint to the side rails of the bed.
 Do not tie the straps of a restraint into a knot.
 Check the skin under the restraint for abrasions.
 Change wet or soiled restraints to prevent skin breakdown.
 Remove a restraint immediately if the patient has an alteration in neurovascular status of an extremity, such
as cyanosis, pallor, or coldness of the skin, or if the patient complains of tingling, pain, or numbness in the
restrained extremity.
OVERVIEW
A physical restraint is any manual method, physical or mechanical device, material, or equipment that immobilizes or
reduces the ability of a patient to move his or her extremities, body, or head freely. 1 A medication may be considered a
chemical restraint when it is given to manage behavior or restrict freedom of movement and is not part of the standard
treatment or dose appropriate for a patient’s condition.2 Physical restraints should be the last resort and used only when
reasonable alternatives fail. Chemical restraints should not be used. The Centers for Medicaid and Medicare Services
(CMS) defines patients’ rights and choices regarding restraints. 1 Restraints have the potential to cause physical harm
(including strangulation), psychological harm, increased agitation, loss of dignity, and even death. The use of restraints is
associated with serious complications, including pressure injuries, hypostatic pneumonia, constipation, incontinence,
contractures, and neurovascular dysfunction.
In certain circumstances, the use of side rails or hand mitts is considered a restraint. Side rails that are intended to
prevent the patient from voluntarily leaving the bed are considered a restraint. 3 However, if the intent of raising the side
rails is to prevent the patient from accidentally falling out of bed, then the rails are not considered a restraint. 3 Hand
mitts that are applied too tightly, pinned or attached to bedding, or used in conjunction with soft wrist restraints meet
the definition of restraint.1 Mitts that significantly impede the patient’s ability to use his or her hands due to the mitt’s
bulkiness are also considered a restraint. 1 Furthermore, mitts that are not easily removed by the patient in the same
manner in which they were applied are considered a restraint. 3 An enclosure bed is considered a physical restraint but is
less restrictive than other types of restraints.4

Patients have the right not to be restrained for coercion or discipline, for the health care team members’ convenience, or
for retaliation. A patient may be restrained only for immediate physical safety of the patient, health care team members,
or others.1

The use of restraints should be limited when physically possible. Less restrictive measures, such as behavioral and
environmental modifications, must be considered before placing a patient in physical restraints. When restraint is
deemed necessary, a practitioner’s order is required. The use and type of restraint must be based on a thorough
assessment of the patient after other therapies or interventions have been deemed ineffective. The ordered restraint
type should be the least restrictive form that protects the patient’s and health care team member’s physical safety. In
emergent situations, the order must be obtained as soon as possible after the restraints have been applied.

The patient’s condition must be monitored frequently to ensure that restraints are discontinued at the earliest possible
time. A scheduled assessment of vital signs and reassessment of safety factors are also important. 6 Restraints should be
discontinued as soon as the unsafe situation has ended or the patient’s needs can be met using less restrictive
measures.6 Guidelines concerning how health care facilities must monitor restrained patients are dictated by regulatory
organizations.
Use of restraints is categorized one of two ways: for violent/self-destructive behavior or for nonviolent behavior. Violent
or self-destructive restraint is the restriction of patient movement for the management of behavior that jeopardizes the
immediate physical safety of the patient, health care team members, or others. Nonviolent restraint is all restraint other
than violent or self-destructive restraint such as when a confused patient is in danger of pulling out an endotracheal
tube.

SUPPLIES
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EDUCATION
 Explain thoroughly the use of restraints. Caution family against removing, repositioning, or retying restraint.
 Encourage questions and answer them as they arise.

ASSESSMENT AND PREPARATION

 Assess the patient’s behavior for confusion; disorientation; agitation; restlessness; combativeness; repeated
removal of tubing or other therapeutic devices; and inability to follow directions.
 Follow your agency’s policy regarding restraints. Check the health care provider’s order for the purpose, type,
location, and time or duration of the restraint. Determine whether a signed consent document for restraint use is
needed.
 Review the manufacturer’s instructions for restraint application, and determine the most appropriate size
restraint.
 Inspect the area where the restraint is to be placed. Note if there is any nearby tubing or devices. Assess the
condition of the patient’s skin, sensation, adequacy of circulation, and range of joint motion.
DELEGATION
The skills of assessing a patient’s behavior and level of orientation, determining the need for restraints, selecting the
appropriate restraint type, and performing the ongoing assessments required while a restraint is in place cannot be
delegated to nursing assistive personnel (NAP).
The application and routine checking of a restraint, however, can be delegated to NAP. The Joint Commission 3 requires
that anyone who monitors a restrained patient, including NAP, be trained in first aid. Be sure to inform NAP of the
following:

 Correct placement of the restraint and how to routinely check the patient’s circulation, skin condition, and
breathing.
 When and how to change a patient’s position or provide range-of-motion exercises, toileting, and skin care.
 To notify you immediately if there is a change in the level of the patient’s agitation, skin integrity, circulation of
the extremities, or breathing.

PROCEDURE
20. Gather the necessary equipment and supplies.
21. Perform hand hygiene.
22. Provide for the patient’s privacy.
23. Use a calm approach and introduce yourself to the patient, including both name and title or role.
24. Verify health care provider’s orders. Determine if signed consent is necessary.
25. Identify the patient using two identifiers, such as the patient’s name and birth date or the patient’s name and
account number.
26. Explain the procedure to the patient and ensure that he or she agrees to treatment. Consult with practitioner for
non-compliant patients and confirm orders before proceeding.
27. Adjust the bed to the proper height, and lower the rail closest to you. Be sure that the patient is comfortable and
in the correct anatomical position.
 28. Inspect the area to which the restraint will be applied. Note any tubes or devices. Assess the patient’s skin
integrity, sensation, circulation, and range of motion.
29. Pad the patient’s skin and bony prominences that will be covered by the restraint as necessary.
30. Apply the proper size restraint, and follow the manufacturer’s instructions for use.
e. Belt restraint: Help the patient into a sitting position. Apply the belt over the patient's clothes, hospital
gown, or pajamas. Smooth out wrinkles or creases in the patient’s clothing. Be sure to place the restraint
at the waist, not the chest or the abdomen. Bring the ties through the slots in the belt. Avoid applying
the belt too tightly. Assist the patient to a supine position if he or she is in bed. Ask the patient to take a
deep breath to ensure there is no restriction to breathing. Attach the restraint securely to a stationary
part of the bed frame.
f. Extremity (ankle or wrist) restraint: Commercially available limb restraints are made of sheepskin or
foam padding. Wrap the limb restraint around the patient’s wrist or ankle, with the soft part toward the
patient’s skin, and secure it snugly, but not tightly, by using the Velcro straps or clips. Check to make sure
the restraint is not too tight by inserting one finger under the secured restraint. Secure the strap through
the D-ring. Use a quick release tie to secure the restraint to the stationary part of the bed frame.
g. Mitt restraint: A thumbless hand mitt device is used to restrain a patient’s hands. Place the patient’s
hand in the mitt, making sure that the Velcro strap(s) are around the patient’s wrist, and not the
forearm. Check to see that one finger slides easily beneath the restraint.
h. Elbow restraint: This device is a rigid, padded, fabric splint that immobilizes the elbow joint. It can be
removed by the patient. This will help the patient stop picking at an IV line. Place restraint around the
patient’s arm so the elbow joint rests against the padded area. Keeping the elbow rigid, secure splint
with Velcro straps. Check fit of restraint. Hook clip to upper end of sleeve of patient’s gown.
31. Reminder: Attach the restraint straps to the stationary part of the bed frame. Be sure the straps are secure. Do
not attach the straps to the side rails. Restraints can be attached to the frame of a chair or a wheelchair as long
as the ties are out of the patient’s reach.
32. Secure the restraints with a quick-release tie, a buckle, or an adjustable seat belt-like locking device. Do not tie
the straps of the restraint into a knot.
33. Double-check to make sure you can insert one finger under any secured restraint.
34. Remove the restraints at least every 2 hours6 or according to your organization’s policy for time specifications for
restraint removal, and assess the patient each time. Assess the proper placement of the restraint, including the
patient’s skin integrity, pulses, temperature, color, and sensation of the restrained body part. If the patient is
violent or noncompliant, remove one restraint at a time, and/or have other health care team members assist you
as you remove the restraints.
35. To ensure the patient's safety, secure the call light or intercom system within reach and lock the wheels on the
patient’s bed or chair. Keep the bed in the lowest position, and raise the appropriate number of side rails.
36. Dispose of used supplies and equipment. Leave the patient's room tidy.
37. Remove and dispose of gloves, if used. Perform hand hygiene.
38. Document and report the patient’s response and expected or unexpected outcomes. Document the type of
restraint, time applied, and reason for restraint.

MONITORING AND CARE

 After applying a restraint, evaluate the patient’s condition for signs of injury every 15 minutes.
 Remove the restraints at least every 2 hours, and assess the placement of the restraint, patient's circulation, skin
condition, position and provide range of motion exercise, toileting and skin care.
 Evaluate the patient for any complications of immobility.
 Routinely observe the patient’s IV catheters, indwelling urinary catheters, and drainage tubes.
 Continually evaluate the patient’s need for restraints according to agency policy.
 When a restraint is used for a patient with violent or self-destructive behavior, a licensed health care provider
must evaluate the patient in person within 1 hour of initiating the restraint.
EXPECTED OUTCOMES
 Patient maintains intact skin integrity, pulses, temperature, color, and sensation of restrained body part.
 Patient is free from injury.
 Patient's therapy (e.g., IV line, catheter) is uninterrupted.
 Patient's self-esteem and dignity are maintained.
 Use of restraints is minimized.
 The least restrictive form of restraint that protects the physical safety of the patient or health care team member
is utilized.

UNEXPECTED OUTCOMES
 Patient experiences impaired skin integrity related to improper or prolonged use of restraint.
 Patient has altered neurovascular status of an extremity, such as cyanosis, pallor and coldness of skin, or
complaints of tingling, pain, or numbness.
 Patient exhibits increased confusion and disorientation.
 Patient releases restraint and suffers a fall or other traumatic injury.
DOCUMENTATION
Documentation Guidelines:
 Record the patient’s behavior before and after the restraints were applied, the patient’s level of orientation, and
the patient’s or family member’s statement of understanding the purpose of the restraint and his or her consent,
if consent is required.
 Record any alternatives to restraints that were attempted and the patient’s response to them.
 Record the reason for the restraint, the type and location, the time at which the restraints were applied, the time
at which the restraints ended, and the routine observations made every 15 minutes (or per agency policy),
including skin color, pulse, sensation, vital signs, and behavior.
 Record unexpected outcomes and related nursing intervention.

Sample Documentation:
2020 Patient has repeatedly attempted to get out of bed. Remains disoriented to name, date, and location. Provided
sitter and attempted to reorient repeatedly without success. Conferred with Dr. Benner. Patient must remain on bed rest
postoperatively after spinal surgery. Dr. Benner here to assess patient; ordered belt restraint for next 24 hours. —M.
Jenkins, RN 8/8/20

2030 Belt restraint applied around waist. Patient able to breathe deeply without restriction. Skin under restraint is intact,
without redness. Patient able to move extremities. Initiating hourly observations of patient and temporary release of
restraints. Family at bedside verbalized understanding of need for restraints postoperatively to reduce risk of disrupting
surgical site. —M. Jenkins, RN 8/8/20

PEDIATRIC CONSIDERATIONS
 Limit the use of restraints to clinically appropriate and adequately justified situations (e.g., examination or
treatment that involves the head and neck) after using all appropriate alternatives. Remain with infant while
restrained and remove restraint immediately after treatment is completed.
 When a child needs to be restrained for a procedure, it is best if the person applying the restraint is not the
child’s parent or guardian.
 When an infant or small child requires a restraint, a papoose board with straps or a mummy wrap using a blanket
or sheet effectively controls his or her movements.

OLDER ADULT CONSIDERATIONS

 Restrained older adults may have increased length of stay and increased risk of adverse outcomes. 7
 Older adults with dementia or altered mental status are at higher risk for use of restraints during hospitalization. 4
HOME CARE CONSIDERATIONS
 A health care provider’s order is needed for use of a restraint in the home. Provide clear, detailed instructions to
the family caregiver, with a return demonstration of restraint application. Do not send a restraint home with
family unless device is necessary to protect patient from injury. Carefully assess the family caregiver for
competency and understanding of intent for using restraint.

REFERENCES
39. Centers for Medicare & Medicaid Services (CMS). (2017). State operations manual: Appendix A—Survey protocol,
regulations and interpretive guidelines for hospitals. Retrieved June 5, 2019, from
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_a_hospitals.pdf
(Level VII)
40. Centers for Medicare and Medicaid Services (CMS). (2011). Programs of all-inclusive care for the elderly (PACE):
Chapter 5—Participant rights and restraint policies. Retrieved June 19, 2019, from
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/pace111c05.pdf (classic
reference)* (Level VII)
41. Joint Commission, The. (2019). Standards FAQ details: Restraint and seclusion—Enclosure beds, siderails and
mitts. Retrieved June 5, 2019, from https://www.jointcommission.org/standards_information/jcfaqdetails.aspx?
StandardsFaqId=1566&ProgramId=46 (Level VII)
42. Harris, J.L. (2015). Enclosure bed: A protective and calming restraint. American Nurse Today, 10(1), 30-31.
Retrieved June 5, 2019, from https://www.americannursetoday.com/wp-content/uploads/2015/01/ant1-
Restraints-1218-ENCLOSURE.pdf
43. Bradas, C.M., Sandhu, S.K., Mion, L.C. (2016). Chapter 23: Physical restraints and side rails in acute and critical
care settings. In M. Bolz and others (Eds.), Evidence-based geriatric nursing protocols for best practice (5th ed.,
pp. 381-394). New York: Springer Publishing Company.
44. Joint Commission, The. (2019). Provision of care, treatment, and services (PC). In K. Byrne (Ed.), 2019 Hospital
accreditation standards. Oak Brook, IL: Joint Commission Resources, Inc. (JCR). (Level VII)
45. Rhodes, S.M. and others. (2016). Predictors of prolonged length of stay and adverse events among older adults
with behavioral health-related emergency department visits: A systematic medical record review. The Journal of
Emergency Medicine, 50(1), 143-152. doi:10.1016/j.jemermed.2015.06.073 (Level III)

*In these skills, a “classic” reference is a widely cited, standard work of established excellence that significantly affects
current practice and may also represent the foundational research for practice.

Elsevier Skills Levels of Evidence

 Level I - Systematic review of all relevant randomized controlled trials
 Level II - At least one well-designed randomized controlled trial
 Level III - Well-designed controlled trials without randomization
 Level IV - Well-designed case-controlled or cohort studies
 Level V - Descriptive or qualitative studies
 Level VI - Single descriptive or qualitative study
 Level VII - Authority opinion or expert committee reports

Supplies
Print Supplies

 Proper restraint, such as a belt, wrist, or hand mitt restraint

 Padding if needed

Test Results
Percentage Correct: 100%
1. To which patient might the nurse apply a physical restraint?

A. An 83-year-old patient with dementia and a history of wandering whose fall risk assessment indicates a high risk of
falling.

B. A 42-year-old critical care patient with a traumatic brain injury who has repeatedly tried to pull out her shunt.

C. A 74-year-old patient confined to bed who is at risk of pressure ulcers.

D. A 60-year-old patient with dementia who seemed increasingly confused shortly after having had restraints applied for
1 hour that morning.

Rationale: The critical care nurse might apply a physical restraint to keep this 42-year-old patient from injuring herself by
dislodging her shunt. Disruption of therapy causes patient injury, pain, or discomfort and increases the risk of infection.
There is no evidence that the use of restraints prevents falls or reduces wandering. Research has shown that patients
suffer fewer injuries if left unrestrained. Use of physical restraints does not prevent pressure injuries; to the contrary,
pressure injury formation is a possible complication associated with the use of physical restraints. Any patient with a
physical restraint must be monitored frequently for skin integrity, pulse, temperature, and color, as well as sensation and
range of motion of the restrained body part. The nurse would not apply a physical restraint to a patient who had
exhibited increased confusion, disorientation, or agitation during the previous application of a restraint. Instead, the
nurse would evaluate the cause of the behavior and try to eliminate it, provide appropriate sensory stimulation, reorient
the patient, use restraint alternatives, and enlist the family’s support if possible.

2. Why does the nurse instruct nursing assistive personnel (NAP) to remove the wrist restraint of a confused patient
every 2 hours?

A. To try a less restrictive type of restraint if a more confining restraint has proved effective

B. To double-check the size by inserting one finger between the wrist and the restraint

C. To check the skin integrity and range of motion of the wrist

D. To comply with Joint Commission standards

Rationale: The nurse instructs the NAP to remove the wrist restraint of a confused patient every 2 hours to ensure that
the wrist is checked for skin integrity, pulse, temperature, color, sensation, and range of motion. In acute care settings,
the health care provider must order the least restrictive type of restraint first, not after a more confining restraint has
proved effective. The nurse would select the appropriate size restraint for the patient, according to the manufacturer’s
instructions, when the restraint is initially applied, and he or she would double-check the fit when the restraint is
applied, not 2 hours later. The fit need not be checked at 2-hour intervals thereafter. The Joint Commission policy states
that, in most circumstances, a physical restraint may be maintained up to 4 hours in an adult.

3. What would the nurse instruct nursing assistive personnel (NAP) to report when caring for a patient in a wrist
restraint?
A. “Tell me if the patient’s pulse changes.”

B. “Tell me if the skin under the restraint becomes abraded or raw.”

C. “Let me know if you think she’s ready for them to come off.”

D. “Let me know if the patient needs anything for pain.”

Rationale: When caring for a patient in a wrist restraint, the nurse would instruct NAP to report the condition of the skin
beneath the restraint. When caring for a patient in a wrist restraint, the nurse would assess the patient for pulse changes
in the extremity to which the restraint has been applied. This skill would not be delegated to NAP. Patient assessment is a
nursing responsibility, and the nurse would make the determination of when a patient’s restraints can be removed, in
accordance with agency policy and all applicable laws and regulations. Assessment of pain is a nursing responsibility and
cannot be delegated to NAP.

4. The nurse is discussing the risk of falling with the wife of a patient with cognitive impairment. What is the nurse’s best
response when the patient’s wife says, “I don’t like him being tied down in the bed?”

A. “I’m sure you don’t want him to fall again.”

B. “Can you suggest an alternative?”

C. “What did you do to prevent him from falling when he was at home?”

D. “We will try all other alternatives before using physical restraints.”
Rationale: The nurse stating they will try all other alternatives before using physical restraints is the correct answer
because the response attempts to reassure the family that restraints will be used only as a last resort. The nurse stating
that you don’t want him to fall again is not the correct answer because it appears to use guilt to secure family consent.
Asking the patient’s wife for an alternative suggestion is not the correct answer because it indicates impatience with the
family’s concerns and places an inappropriate responsibility on the patient’s wife. Asking the patient’s wife what she did
to prevent him from falling when he was at home is not the correct option, because it appears to place responsibility for
the patient’s safety on the family. In addition, the patient’s condition and circumstances are different in the facility than
they were at home, so using the same fall-prevention strategies is likely to be ineffective.
5. When a nursing assistive personnel (NAP) enters the room of a patient in a belt restraint, he finds the patient’s gown
bunched around the patient’s chest and the patient asking for help. What would the NAP do?
A. Check the patient’s blood pressure and pulse before smoothing the gown

B. Untie the restraint and smooth the patient’s gown

C. Put on the call light for help

D. Ask the patient what specific help she would like

Rationale: The NAP would untie the restraint, smooth the patient’s gown, and replace the restraint. Checking the
patient’s blood pressure and pulse is not appropriate at this time. Putting on the call light is not appropriate, since the
call light is intended to summon the NAP. Asking the patient what help is needed is not appropriate. The difficulty is
obvious, and the patient may have a cognitive impairment that makes clear expression of his or her needs impossible.