Which situation indicates a need for the nurse to discuss mitten restraints with the healthcare provider?

• A. A disoriented client removed the mesh-wrapped IV line for the second time
• B. A patient requests a snack
• C. A patient asks for more privacy during care
• D. A confused patient agrees to hold still during IV insertion

Answer: (A)

The situation tests safety planning for confused or disoriented patients. When a patient is disoriented and repeatedly pulls at IV lines, there is a real risk of self-injury or device disruption. In such cases, mittens or other restraints may be considered to prevent harm, but this requires a provider’s order after evaluating the risks and confirming that no less restrictive measures are sufficient. The goal is to use restraints only as a last resort and to monitor the patient closely, review the underlying cause of confusion, and try alternatives first (such as closer supervision, reorientation, or adjusting the environment). The other scenarios—seeking a snack, asking for more privacy, or agreeing to hold still—do not create an immediate safety threat that would necessitate restraints.