A confused patient with a urinary catheter,a nasogastric tube,and an intravenous line keeps touching these items,which are needed for care.The nurse has tried to explain to the patient that he should not touch them,but the patient continues.What is the best action by the nurse at this time?

A) Apply restraints loosely on the patient's dominant wrist.
B) Try other approaches to prevent the patient from touching these care items.
C) Notify the health care provider that restraints are needed immediately to maintain the patient's safety.
D) Allow the patient to pull out lines to prove that the patient needs to be restrained.

The risks associated with the use of restraints are serious.With regard to restraints,a restraint-free environment is the first goal of care for all patients.Many alternatives to the use of restraints are available,and the nurse should try all of them before notifying the patient's health care provider.In this situation,the patient is touching the items,not trying to pull them out;therefore,at this time,the patient's well-being is not at risk.The nurse will have to check on the patient frequently and then will determine whether the health care provider needs to be informed of the situation.The inappropriate or unjustified use of restraints (e.g. ,by confining a person to an area or by using physical or chemical restraints)may also be viewed as false imprisonment.The health care provider needs to know the situation but also needs to ensure that all approaches possible are used before restraints are ordered.Allowing the patient to pull out any of these items could cause harm to the patient.