ANS: D Show Numerous factors increase the risk of falls, including a history of falling, being age 65 or over, reduced vision, orthostatic hypotension, lower extremity weakness, gait and balance problems, urinary incontinence, improper use of walking aids, and the effects of various medications (e.g., anticonvulsants, hypnotics, sedatives, certain analgesics). DIF:Understand (comprehension)REF:375 | 388 OBJ: Describe assessment activities designed to identify a patient's physical, psychosocial, and cognitive status as it pertains to his or her safety. TOP: Assessment MSC: Safety and Infection Control ANS: B Patients who are confused, disoriented, and wander or repeatedly fall or try to remove medical devices (e.g., oxygen equipment, IV lines, or dressings) often require the temporary use of restraints to keep them safe. Restraints can be used to prevent interruption of therapy such as traction, IV infusions, NG tube feeding, or Foley catheterization. Refusing to call for help, although unsafe, is not a reason for restraint. Getting confused at night regarding the time or not sleeping and bothering the staff to ask for items is not a reason for restraint. DIF:Apply (application)REF:391 OBJ: Describe assessment activities designed to identify a patient's physical, psychosocial, and cognitive status as it pertains to his or her safety. TOP: Assessment MSC: Safety and Infection Control 18. The nurse is monitoring for the four categories of risk that have been identified in the health care environment. Which examples will alert the nurse that these safety risks are occurring? a. Tile floors, cold food, scratchy linen, and noisy alarms b. Dirty floors, hallways blocked, medication room locked, and alarms set c. Carpeted floors, ice machine empty, unlocked supply cabinet, and call light in reach d. Wet floors unmarked, patient pinching fingers in door, failure to use lift for patient, and alarms not functioning properly ANS: D Specific risks to a patient's safety within the health care environment include falls, patient-inherent accidents, procedure-related accidents, and equipment-related accidents. Wet floors contribute to falls, pinching finger in door is patient inherent, failure to use the lift is procedure related, and an alarm not functioning properly is equipment related. Tile floors and carpeted or dirty floors do not necessarily contribute to falls. Cold food, ice machine empty, and hallways blocked are not patient-inherent issues in the hospital setting but are more of patient satisfaction, infection control, or fire safety issues. Scratchy linen, unlocked supply cabinet, and medication room locked are not procedure-related accidents. These are patient satisfaction issues and control of supply issues and are examples of actually following a procedure correctly. Noisy alarms, call light within reach, and alarms set are not equipment-related accidents but are examples of following a procedure correctly. DIF:Apply (application)REF:379 OBJ: Describe the four categories of safety risks in a health care agency. TOP: Evaluation MSC: Safety and Infection Control 30. The nurse enters the patient's room and notices a small fire in the headlight above the patient's bed. In which order will the nurse perform the steps, beginning with the first one? 1. Pull the alarm. 2. Remove the patient. 3. Use the fire extinguisher. 4. Close doors and windows. a. 2, 1, 4, 3 b. 1, 2, 4, 3 c. 1, 2, 3, 4 d. 2, 1, 3, 4 ANS: B, C, E, F Proper documentation, including the behaviors that necessitated the application of restraints, the procedure used in restraining, the condition of the body part restrained (e.g., circulation to hand), and the evaluation of the patient response, is essential. Record nursing interventions, including restraint alternatives tried, in nurses' notes. Record purpose for restraint, type and location of restraint used, time applied and discontinued, times restraint was released, and routine observations (e.g., skin color, pulses, sensation, vital signs, and behavior) in nurses' notes and flow sheets. Straps are not attached to side rails. Comments about the activities of one family member are not necessarily required in nursing documentation of restraints. DIF:Apply (application)REF:392 | 403 OBJ:Identify the factors to assess when a patient is in restraints. TOP: Communication and Documentation MSC: Safety and Infection Control Terms in this set (79)A nursing instructor explains that a complete nursing diagnosis may be a one-part, two-part, or three-part statement. Three-part statements are often called PES statements, which stands for A nursing instructor educates a class of nursing students about SOAPIER charting. The nursing instructor teaches that the acronym SOAPIER stands for The method of charting that provides a continual description of a patient's condition, complaints, problems, assessment findings, activities, treatments, and nursing care, along with the evaluations of effectiveness for each nursing intervention from admission through discharge, is known as Students also viewedWhat type of order is required before applying a restraint?A complete doctor's order is needed to initiate the use of restraints except under extreme emergency situations when a registered nurse can initiate the emergency use of restraints using an established protocol until the doctor's order is obtained and/or the dangerous behaviors no longer exist.
Which intervention should a nurse implement before applying restraints?Before applying restraints, the nurse must exhaust alternative measures to restraints such as a bed alarm, distraction, and a sitter. If the nurse determines that a restraint is necessary, its use is discussed with the client and family and a prescription is obtained from the health care provider.
What needs to be assessed and documented while a patient is in restraints?The patient restrained for the management of violent or self-destructive behavior will be under continuous observation with documentation by a NA/Sitter of patient activity every 15 minutes. Nurse will document a nursing assessment to include respiratory status, circulatory status, range of motion, and behavior.
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Quizlet which would be placed in the medical record before implementing the use of restraints
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