Question

4. A patient has been placed in physical restraints by an order of the healthcare provider. What nursing responsibilities exist? Select all that apply. A. The nurse applies a pulse oximeter. B. The nurse monitors the vitals signs. C. The nurse monitors the patient visually continuously. D. The nurse puts up the side rails before leaving the client’s room. E. The nurse withholds food and fluids during the time that the restraints are in place.

5. In which circumstances are restraints appropriate? Select all that apply. A. A patient is threatening to harm himself. B. The patient is exhibiting violent behavior toward others on the unit. C. The patient is becoming increasingly unruly and loud, disrupting the unit. D. The patient is refusing to take his prescribed, required medication on time. E. The patient was rude, spit on the floor, and laughed at the staff on the unit.

6. Upon initiating the use of restraints on a patient for violent or self-destructive behavior, the healthcare provider must perform a face-to-face patient evaluation within what time frame? A. 15 minutes B. 1 hour C. 4 hours D. 24 hours

7. Joe is an 18-year-old admitted to the emergency department with a suspicion of drug intoxication. While he is lethargic, slightly disoriented, and answering questions in an annoyed manner, he appears to be cooperative. An IV is placed for hydration and for medication administration. The nurse is concerned that he may become violent and takes which appropriate action: A. Placing him in restraints as he may become violent B. Placing him in restraints to prevent him pulling out his IV line C. Placing him in seclusion as he may try to hurt the staff D. He requires no restraint at this time – his behavior doesn’t warrant restraints

8. Patients in restraints for violent and self-destructive behavior must be monitored by: A. hourly rounding B. a volunteer family member C. every 15 minute in-person checks D. continuous, in-person, 1:1 monitoring

Answer 1

Restrains are used to restrict the patient movements. It can help keep a person from getting hurt or doing harm to others, including their caregivers. two types of restrains, physical restrain and chemical restrains.

physical restrains eg mummy restains, extrimity restrains, abdominal restrains etc

Chemical restrains are administration of drugs ,usually sedatives or antipsychotic as per doctors order.

What are the key factors to be checked with the patient with restarain?

• second hourly vital signs
• elemination needs
• nutritional needs
• check of circulation
• consent to be renewed every 24 hours
• physician order must to be repeat every 8 th hourly

4. A patient has been placed in physical restraints by an order of the healthcare provider. What nursing responsibilities exist? Select all that apply.

A. The nurse applies a pulse oximeter.

B. The nurse monitors the vitals signs.

C. The nurse monitors the patient visually continuously.

D. The nurse puts up the side rails before leaving the client’s room.

E. The nurse withholds food and fluids during the time that the restraints are in place.

With physical restrains nurse must check the second hourly vital signs, oxygen saturation levels, continuous visual monitoring, all ways put ups the side rails before living client's room , nurse need not to with hold the fluids and water because it is our responsibility to meet the patients nutritional needs. According to the patients co operation we can take decision regarding food and fluid intake must to be with hold or not.

5. In which circumstances are restraints appropriate? Select all that apply.

A. A patient is threatening to harm himself.

B. The patient is exhibiting violent behavior toward others on the unit.

C. The patient is becoming increasingly unruly and loud, disrupting the unit.

D. The patient is refusing to take his prescribed, required medication on time.

E. The patient was rude, spit on the floor, and laughed at the staff on the unit.

Ans: A&B

A. A patient is threatening to harm himself.

Eg he is pulling out IV line, or other tubes , running out of your control , patient with psychatric disorder not under control Etc

B. The patient is exhibiting violent behavior toward others on the unit. can be applicable for

for restrains.Eg He is beats his relatives, nursing staffs or others in the ward, throwing things away

C. The patient is becoming increasingly unruly and loud, disrupting the unit.- you need not restrain try to calm your patient, ask regarding his querries and fulfill it if possible

D. The patient is refusing to take his prescribed, required medication on time- refusal of medication is patients rigts , document it in your nursing notes, reassure the patient and encourage him to take medicines.

E. The patient was rude, spit on the floor, and laughed at the staff on the unit.- this is mostly patient is in arrogant behaviour unless he is harming himself or others we cannot go with restrains.

6. Upon initiating the use of restraints on a patient for violent or self-destructive behavior, the healthcare provider must perform a face-to-face patient evaluation within what time frame?

A. 15 minutes - safty and comfort check

B. 1 hour - check the patient face to face regarding medical condition, behavioural condition , patient reaction to restrains, need to continue?

C. 4 hours -check Range of motion , circulation, skin integrity, mental status, patient reaction to restrains

D. 24 hours--Review the plan of care.

7. Joe is an 18-year-old admitted to the emergency department with a suspicion of drug intoxication. While he is lethargic, slightly disoriented, and answering questions in an annoyed manner, he appears to be cooperative. An IV is placed for hydration and for medication administration. The nurse is concerned that he may become violent and takes which appropriate action:

A. Placing him in restraints as he may become violent

B. Placing him in restraints to prevent him pulling out his IV line

C. Placing him in seclusion as he may try to hurt the staff

D. He requires no restraint at this time – his behavior doesn’t warrant restraints-At this poin he is in lethargic slightly dis oriented, answerring questions in annoyed manner. he did not show any signs of self harmful or exibit violent behaviour to nursing staffs , keep the restrains ready and watch the patient carefully. he appers to be co operative also.

8. Patients in restraints for violent and self-destructive behavior must be monitored by:

A. hourly rounding

B. a volunteer family member

C. every 15 minute in-person checks

D. continuous, in-person, 1:1 monitoring

A patient with restrains must be check every 15 hours for his safety and comfort check,

A volunteer family member can check the patient and be with him , if the family member is okay with the patient. if the family member is under grief better to be avoid them

Hourly rounding for monitoring medical condition, behaviour condition, patient reaction to restrains, need to continue restrains.

Preferably continuous 1:1 monitoring is good for patient safty