Texas Board of Nursing (BON) Practice Exam

What should a nurse document following an incident involving patient restraint?

1. The reason for the restraint and the patient's response

2. Only the duration of the restraint

3. The nurse's personal feelings about the incident

4. The names of witnesses present during the incident

The correct answer is: The reason for the restraint and the patient's response

Documenting the reason for the restraint and the patient's response is crucial in ensuring patient safety and legal accountability. When a nurse restrains a patient, it is necessary to record the clinical justification for the restraint, including any specific behaviors or events leading up to that decision. This documentation not only communicates why the restraint was necessary, but it also aids in evaluating the patient's response to the restraint, which is essential for assessing its effectiveness and the patient's well-being. Proper documentation is key in establishing a clear and accurate medical record, which can be referenced later for continuation of care, as well as being important in any legal or regulatory reviews that might occur after the incident. Thorough documentation serves as protection for both the patient and the healthcare provider, illustrating that the restraint was not used lightly but rather as a measure to ensure safety.