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3.4 Fall Prevention and Restraints

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NCLEX-RN Registered Nurse

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1 Introduction

About the NCLEX-RN Exam Next Generation NCLEX (NGN) Clinical Judgment Measurement Model (NCJMM) How to Use This Course

2 Chapter 2: Management of Care

2.1 Legal Rights and Responsibilities 2.2 Advance Directives and Self-Determination 2.3 Informed Consent Protocols 2.4 Client Advocacy and Rights (HIPAA) 2.5 Assignment, Delegation, and Supervision 2.6 Five Rights of Delegation 2.7 Scope of Practice (RN vs LPN vs UAP) 2.8 Ethical Practice Principles

3 Chapter 3: Safety and Infection Prevention and Control

3.1 Standard Precautions and Hand Hygiene 3.2 Transmission-Based Precautions (Contact, Droplet, Airborne) 3.3 PPE Donning and Doffing Sequences 3.4 Fall Prevention and Restraints 3.5 Fire Safety (RACE/PASS) 3.6 Disaster Triage and Emergency Response

4 Chapter 4: Health Promotion and Maintenance

4.1 Growth and Development (Erikson/Piaget) 4.2 Developmental Stages: Infancy through Older Adult 4.3 Maternal and Newborn Care (Antepartum) 4.4 Intrapartum Care and Fetal Monitoring 4.5 Postpartum Care (BUBBLE-HE) 4.6 Health Screening Guidelines 4.7 Immunization Schedules

5 Chapter 5: Psychosocial Integrity

5.1 Therapeutic Communication Techniques 5.2 Non-Therapeutic Communication (What to Avoid) 5.3 Anxiety Disorders and Mental Health Concepts 5.4 Schizophrenia: Hallucinations and Delusions 5.5 Depression and Suicide Assessment 5.6 Substance Misuse and Withdrawal 5.7 Grief and End-of-Life Care

6 Chapter 6: Basic Care and Comfort

6.1 Mobility and Hazards of Immobility 6.2 Assistive Devices (Crutches, Canes, Walkers) 6.3 Nutrition and Diet Therapy 6.4 Enteral Nutrition (Tube Feeding) 6.5 Bowel Elimination and Ostomy Care 6.6 Urinary Elimination and Catheter Care

7 Chapter 7: Pharmacological and Parenteral Therapies

7.1 Medication Administration Rights 7.2 Medication Calculations 7.3 High-Alert Medications: Insulins 7.4 High-Alert Medications: Anticoagulants 7.5 High-Alert Medications: Opioids 7.6 High-Alert Medications: Digoxin and Electrolytes 7.7 IV Therapy and Complications 7.8 Blood Product Administration 7.9 Total Parenteral Nutrition (TPN)

8 Chapter 8: Reduction of Risk Potential

8.1 Laboratory Values: Hematology (CBC) 8.2 Laboratory Values: Metabolic Panel (BMP) 8.3 Laboratory Values: Coagulation Studies 8.4 Vital Signs and Trend Recognition 8.5 Perioperative Care (Pre-Op and Post-Op) 8.6 Nasogastric Tubes and Therapeutic Procedures

9 Chapter 9: Physiological Adaptation

9.1 Fluid Imbalances (Hypovolemia and Hypervolemia) 9.2 Arterial Blood Gases (ABGs) and Acid-Base Balance 9.3 Medical Emergencies: Stroke (CVA) 9.4 Medical Emergencies: Myocardial Infarction (MONA) 9.5 Diabetic Emergencies (Hypoglycemia and DKA) 9.6 Respiratory Conditions (COPD, Pneumonia) 9.7 Cardiac Conditions (Heart Failure) 9.8 Neurological Conditions (Seizures)

3.4 Fall Prevention and Restraints

Key Takeaways Explain This Topic AI

Fall risk factors include advanced age, sedating medications, confusion, mobility impairments, and urinary urgency/incontinence

Fall prevention interventions include bed alarms, non-skid footwear, low bed position, adequate lighting, and assistive devices within reach

Restraints are a measure of LAST resort and require a provider order that must be renewed every 24 hours for non-violent situations

PRN (as needed) restraint orders are NEVER acceptable - each restraint use requires a specific time-limited order

Patients in restraints require assessment every 30 minutes to 2 hours including circulation, sensation, skin integrity, and release for ROM exercises

Last updated: January 2026

Falls are one of the most common adverse events in healthcare facilities, particularly affecting older adults. The NCLEX tests your understanding of risk assessment, prevention strategies, and the proper use of restraints as a last resort.

  • Fall Risk Assessment
  • High-Risk Populations
  • Risk Factor Clinical Examples
  • Age Adults over 65 years old
  • Medications Sedatives, opioids, diuretics, antihypertensives
  • Cognition Confusion, delirium, dementia
  • Mobility Gait disturbances, weakness, balance issues
  • Vision Impaired vision, recent eye surgery
  • Elimination Urinary urgency, incontinence, frequent toileting
  • Environment Unfamiliar surroundings, clutter, wet floors
  • History Previous falls within past 3 months
  • Standardized Assessment Tools

Most facilities use validated fall risk assessment tools:

  • Morse Fall Scale - Most commonly used; scores 6 risk factors
  • Hendrich II Fall Risk Model - Includes confusion and symptomatic depression
  • STRATIFY - Validated for acute hospital settings
  • Fall Prevention Interventions
  • Environmental Modifications
  • Intervention Rationale
  • Bed in lowest position Reduces injury if patient falls from bed
  • Side rails (1-2) up Assists with repositioning; not restraint when patient can exit
  • Call light within reach Enables patient to summon help
  • Non-skid footwear Prevents slipping on smooth floors
  • Adequate lighting Improves visibility; nightlights for nighttime
  • Clear pathways Removes obstacles that could cause tripping
  • Assistive devices nearby Walker, cane within reach when needed
  • Patient-Centered Interventions
  • Intervention Rationale
  • Bed/chair alarms Alerts staff when patient attempts to stand
  • Frequent rounding Proactive toileting and needs assessment
  • Toileting schedule Reduces urgency-related ambulation
  • Hip protectors Reduces injury severity if fall occurs
  • Fall risk signage Communicates risk to all staff
  • Patient/family education Engages patient in prevention
  • Medication Review

Evaluate and minimize:

  • Sedatives and hypnotics
  • Opioid analgesics
  • Antihypertensives (orthostatic hypotension)
  • Diuretics (urgency, electrolyte imbalances)
  • Psychotropic medications
  • Restraints: Last Resort Only

Restraints are defined as any device, method, or process that restricts a patient's freedom of movement or access to their body. This includes:

  • Physical devices (wrist, ankle, vest, belt restraints)
  • Medication used primarily for control (chemical restraint)
  • Seclusion (confinement in a room patient cannot leave)
  • Core Principle

Restraints are a measure of LAST resort - used only when less restrictive interventions have failed and the patient poses an immediate threat to self or others.

Types of Restraints

  • Type Description Example
  • Limb restraints Restrict movement of arms or legs Wrist restraints, ankle restraints
  • Vest/Jacket Restrict trunk movement Vest tied to bed frame
  • Belt restraints Keep patient in chair or bed Waist belt
  • Mitt restraints Prevent hand/finger use Padded mitts prevent pulling tubes
  • Enclosed beds Prevent patient from leaving bed Canopy beds, safety enclosures
  • Chemical restraints Medications for behavioral control Haloperidol for acute agitation
  • Restraint Requirements
  • Provider Order Requirements
  • Situation Order Requirements
  • Non-violent (medical/surgical) Written order within 1 hour; renewed every 24 hours
  • Violent/self-destructive (adult) Written order within 1 hour; renewed every 4 hours
  • Violent/self-destructive (child 9-17) Renewed every 2 hours
  • Violent/self-destructive (child under 9) Renewed every 1 hour
  • Critical Rules
  • PRN orders are NEVER acceptable - Each restraint use requires a specific, time-limited order
  • Face-to-face evaluation required within 1 hour for violent restraints
  • Continuous monitoring is required
  • Least restrictive device must be used
  • Documentation must include alternatives tried and failed
  • Monitoring Patients in Restraints

Assessment must occur at regular intervals (typically every 30 minutes to 2 hours based on facility policy):

  • Assessment Area What to Check
  • Circulation Pulses distal to restraint, color, temperature, capillary refill
  • Sensation Numbness, tingling
  • Skin integrity Redness, breakdown, abrasions
  • Range of motion Release periodically for ROM exercises
  • Psychological status Agitation, distress
  • Vital signs Temperature, pulse, respirations
  • Nutrition/hydration Offer fluids, meals
  • Elimination Toileting needs
  • Continued need Reassess if restraint is still necessary
  • Release Schedule

Remove restraints at least every 2 hours for:

  • Range of motion exercises
  • Skin care
  • Toileting
  • Repositioning
  • Restraint Alternatives

Before applying restraints, try these alternatives:

  • Category Interventions
  • Environmental Move closer to nursing station, low bed, floor mats
  • Distraction Music, television, conversation, activities
  • Comfort Pain management, toileting, positioning
  • Family Invite family member to stay with patient
  • Staffing 1:1 sitter observation
  • Assessment Treat underlying cause (delirium, pain, infection)
  • Legal and Ethical Considerations
  • Restraints can be considered false imprisonment if used improperly
  • Patient has right to be free from restraint unless necessary for safety
  • Least restrictive intervention must always be used first
  • Documentation is critical - must show medical necessity and alternatives tried
  • Death in restraints is a sentinel event requiring root cause analysis
  • On the NCLEX

Common testing points:

  • Identifying patients at high risk for falls
  • Priority interventions for fall prevention
  • Understanding that restraints require orders (not PRN)
  • Assessment frequency for restrained patients
  • Legal implications of restraint use

Exam Strategy: If a question asks about restraints, the answer usually involves trying alternatives first, obtaining a proper order, or assessing circulation/skin integrity.