In evaluating the effectiveness of the restraint, it is important that the nurse
:a. Document the response of the client's family to the use of the restraint on the client
.b. Observe the family's behavior while the client is in restraints.
c. Document the exact times the restraint is applied and removed
.d. Observe the client's behavior while in the restraint and document the behavior.
d. Observe the client's behavior while in the restraint and document the behavior.
Rationale: Documentation is important but evaluation of the effectivenessof the restraint needs to focus on the behavior of the client while in restraint.The nurse needs to observe how the client is responding to the restraint.The family’s response or the family’s behavior is to be observed but theseare not ways of evaluating effectiveness. Documenting the exact times therestraint is applied and removed is important, but it is not the primarynursing focus for determining restraint effectiveness.