Download NURS 465 Exam 2: Patient Rights, Restraint, Seclusion, and Crisis Intervention and more Exams Nursing in PDF only on Docsity!
nurs 465 exam 2 Questions and answers
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Patient's II!Bill II!of II!Rights II!- II! II!Correct II!Answers II! II! II! II!all II!patients II!have II!the II!right II!to:
- II!privacy
- II!refusal II!of II!treatment II!or II!medications
- II!least II!restrictive II!environment
- II!informed II!consent
- II!make II!/ II!receive II!phone II!calls II!
- II!send II!/ II!receive II!mail II!APD II!(advanced II!psychiatric II!directive) II!- II! II!Correct II!Answers II! II! II! II!an II!APD II!identifies II!a II!patients II!treatment II!choices II!and II!surrogate II!decision II!maker. II!implied II!consent II!- II! II!Correct II!Answers II! II! II! II!client II!adheres II!to II!instructions II!provided II!by II!the II!nurse; II!ex: II!the II!nurse II!is II!preparing II!to II!administer II!a II!TB II!test II!and II!the II!client II!holds II!out II!his II!arm II!for II!the II!nurse. II!what II!is II!the II!exception II!for II!the II!right II!to II!refuse II!treatment? II!- II! II!Correct II!Answers II! II! II! II!a II!patient II!cannot II!refuse II!treatment II!in II!an II!emergency II!event II!to II!prevent II!serious II!and II!imminent II!harm II!to II!self II!or II!others. II!Restraint II!(definiton) II!- II! II!Correct II!Answers II! II! II! II!Any II!manual II!method, II!physical II!or II!mechanical II!device, II!material, II!or II!equipment II!that II!restricts II!freedom II!of II!movement II!seclusion II!(definition) II!- II! II!Correct II!Answers II! II! II! II!involuntary II!confinement II!in II!locked II!room II!equipped II!with II!security II!window II!or II!camera II!for II!direct II!visual II!monitoring II!rules II!for II!use II!of II!restraint II!+ II!seclusion II!(S II!& II!R) II!- II! II!Correct II!Answers II! II! II! II!1. II!use II!only II!for II!shortest II!time II!necessary
- II!Permitted II!only II!when II!client II!is II!imminently II!aggressive/dangerous
- II!patient II!needs II!a II!1:1 II!and II!on II!observation
II!Immediate II!risk II!of II!harm II!to II!the II!patient II!or II!others II!Alternative, II!less-restrictive II!measures II!fail II!to II!protect II!the II!patient II!and II!others II!from II!harm. II!- II! II!Correct II!Answers II! II! II! II!when II!is II!S II!& II!R II!authorized II!as II!interventions: II!Contraindications II!for II!Seclusion II!& II!Restraint II!- II! II!Correct II!Answers II! II! II! II!Extremely II!unstable II!medical II!& II!psychiatric II!conditions Clients II!with II!suicide II!risk Client II!experiencing II!drug II!reaction II!or II!OD Punishment II!or II!for II!staff II!convenience II!rules II!for II!involuntary II!admission II!- II! II!Correct II!Answers II! II! II! II!-Must II!present II!a II!clear II!risk II!of II!harm II!to II!self II!or II!others.
- Pt II!may II!be II!held II!on II!an II!emergency II!basis II!for II!a II!limited II!period II!of II!time II!against II!their II!will.
- Inability II!to II!care II!for II!self. II!AMA II!- II! II!Correct II!Answers II! II! II! II!patient II!signs II!out II!against II!medical II!advice II!from II!inpatient II!treatment. II!
- II!** II!Cannot II!hold II!patient II!who II!presents II!no II!risk II!to II!self II!or II!others II!this II!is II!false II!imprisonment II!** II!Exceptions II!to II!client II!confidentiality II!- II! II!Correct II!Answers II! II! II! II!1) II!The II!client II!is II!dangerous II!and II!made II!specific II!threats II!of II!violence II!toward II!an II!identified, II!accessible II!person II!with II!the II!means II!to II!carry II!the II!act II!out
- II!The II!client II!is II!a II!minor, II!elderly, II!or II!disabled II!& II!is II!thought II!to II!be II!a II!victim II!of II!abuse; II!nurses II!are II!mandated II!reporters
- II!Disclosures II!that II!must II!be II!made II!to II!other II!professionals II!for II!coordination II!of II!care II!orII!insurance II!issues II!unintentional II!tort II!- II! II!Correct II!Answers II! II! II! II!Negligence, II!malpractice, II!conduct II!that II!falls II!below II!a II!standard II!of II!care II!necessary II!to II!protect II!others II!from II!unreasonable II!risks II!of II!harm. II!Negligence II!/Malpractice II!- II! II!Correct II!Answers II! II! II! II!An II!act II!or II!an II!omission II!that II!breaches II!the II!duty II!of II!due II!care II!& II!results II!in II!or II!is II!responsible II!for II!a II!person's II!injuriesImproper, II!illegal, II!negligent II!professional II!activity II!or II!treatmentPractice II!beyond II!your II!scope II!of II!practice II!Elements II!of II!Nursing II!Negligence II!- II! II!Correct II!Answers II! II! II! II!-Duty II!of II!due II!care II!established II!(measured II!by II!standard II!of II!care)
Phase II!4: II!If II!the II!problem II!is II!not II!solved II!and II!new II!coping II!skills II!are II!ineffective, II!then II!anxiety II!can II!overwhelm II!the II!person II!and II!lead II!to II!serious II!illness; II!assess II!for II!suicidal II!thoughts. II!maturational II!crisis II!- II! II!Correct II!Answers II! II! II! II!Developmental II!events II!requiring II!role II!change
- I.e II!marriage, II!parenthood II!situational II!crisis II!- II! II!Correct II!Answers II! II! II! II!change II!that II!results II!when II!a II!person II!faces II!an II!event II!or II!situation II!that II!causes II!a II!disruption II!in II!one's II!life
- II!i.e II!loss II!of II!job, II!loss II!of II!loved II!one, II!divorce II!traumatic II!crisis II!- II! II!Correct II!Answers II! II! II! II!AII!crisis II!initiated II!by II!unexpected, II!unusual II!events II!in II!which II!people II!face II!overwhelming II!hazards II!thatII!entail II!injury, II!trauma, II!destruction, II!or II!sacrifice. II!
- May II!affect II!an II!individual II!or II!a II!multitude II!of II!people II!at II!once. II!Grieving/bereavement II!- II! II!Correct II!Answers II! II! II! II!process II!by II!which II!person II!experiences II!grief; II!content, II!process II!anticipatory II!grieving II!- II! II!Correct II!Answers II! II! II! II!acknowledging II!that II!the II!loss II!is II!inevitableII!and II!preparing II!emotionally II!for II!it II!mourning II!- II! II!Correct II!Answers II! II! II! II!the II!act II!of II!showing II!sorrow II!or II!grief II!types II!of II!loss II!- II! II!Correct II!Answers II! II! II! II!-Physiologic II!loss
- Safety II!loss
- Loss II!of II!security II!and II!sense II!of II!belonging
- Loss II!of II!self-esteem
- Loss II!related II!to II!self-actualization II!berevement II!- II! II!Correct II!Answers II! II! II! II!acknowledgement II!of II!the II!objective II!fact II!that II!one II!has II!experienced II!a II!death II!and II!the II!period II!of II!grief II!and II!mourning II!after II!a II!death.
II!Greif II!- II! II!Correct II!Answers II! II! II! II!deep II!sorrow, II!especially II!that II!caused II!by II!someone's II!death.
- II!part II!of II!the II!normal II!process II!of II!reacting II!to II!death
- II!it II!is II!the II!emotional II!response II!to II!loss II!stages II!of II!grief II!- II! II!Correct II!Answers II! II! II! II!1. II!Denial
- II!Anger
- II!Bargaining
- II!Depression
- II!Acceptance II!Six II!R's II!inII!grief II!- II! II!Correct II!Answers II! II! II! II!recognize react recollect relinquish readjust reinvest II!disenfranchised II!grief II!- II! II!Correct II!Answers II! II! II! II!A II!situation II!in II!which II!certain II!people, II!although II!they II!are II!bereaved, II!are II!prevented II!from II!mourning II!publicly II!by II!cultural II!customs II!or II!social II!restrictions. II!complicated II!greif II!- II! II!Correct II!Answers II! II! II! II!Person II!void II!of II!emotion; II! grieving II!for II!prolonged II!periods; II! expressions II!of II!grief II!seem II!disproportionate II!to II!event. Previously II!existing II!psychiatric II!disorders II!may II!complicate II!process. Clients II!can II!experience II!grief II!when II!change II!encountered. II!risk II!factors II!for II!complicated II!grief II!- II! II!Correct II!Answers II! II! II! II!loss II!of II!child; II!overly II!lengthy II!illness; II!perception II!of II!preventability; II!lack II!of II!social II!support; II!type II!of II!death II!(e.g. II!suicide, II!AIDS)
II!Suicide II!Warning II!Signs II!- II!"Is II!Path II!Warm?" II!- II! II!Correct II!Answers II! II! II! II!I II!- II!ideation S II!- II!subtance II!abuse P II!- II!purposelessness A II!- II!anxiety II!and II!agitation T II!- II!feeling II!trapped H II!- II!hopelessness W II!- II!withdrawal A II!- II!anger R II!- II!recklessness M II!- II!moodII!fluctuations II!nursing II!interventions II!goals II!for II!suicide: II!- II! II!Correct II!Answers II! II! II! II!Using II!an II!authoritative II!role Providing II!a II!safe II!environment Creating II!a II!support II!system II!list II!major II!depression II!- II! II!Correct II!Answers II! II! II! II!a II!disorder II!characterized II!by II!severe II!negative II!moods II!or II!a II!lack II!of II!interest II!in II!normally II!pleasurable II!activities II!major II!depressive II!episode II!- II! II!Correct II!Answers II! II! II! II!an II!episode II!characterized II!by II!symptoms II!such II!as II!feelings II!of II!intense II!hopelessness, II!low II!self-esteem II!and II!worthlessness, II!extreme II!fatigue, II!dramatic II!changes II!in II!eating II!and II!sleeping II!behavior, II!inability II!to II!concentrate, II!and II!greatly II!diminished II!interest II!in II!family, II!friends, II!and II!activities II!for II!a II!period II!of II! 2 II!weeks II!or II!more II!Dysthymic II!disorder II!- II! II!Correct II!Answers II! II! II! II!a II!mood II!disorder II!involving II!a II!pattern II!of II!comparatively II!mild II!depression II!that II!lasts II!for II!at II!least II!two II!years II!Cyclothymic II!disorder II!- II! II!Correct II!Answers II! II! II! II!a II!disorder II!marked II!by II!numerous II!periods II!of II!hypomanic II!symptoms II!and II!mild II!depressive II!symptoms
II!nuerotrasmitters II!thought II!to II!be II!involved II!in II!bipolar II!and II!depression II!- II! II!Correct II!Answers II! II! II! II!seratoinin, II!dopamine, II!acetylcholine, II!norepinephrine II!BIOLOGICAL II!THEORIEs II!of II!depression II!- II! II!Correct II!Answers II! II! II! II!- II!Genetic II!theory
- II!Neurotransmitter II!theories II!- II!catecholamines, II!dopamine, II!noriepinephrine
- II!Structural II!and II!functional II!brain II!abnormalities
- II!Neuroendocrine II!factors II!acute II!phase II!of II!mania II!- II! II!Correct II!Answers II! II! II! II!1.) II!Medical II!stabilization 2.) II!Maintaining II!safety 3.) II!Self-care II!needs II!(poor II!hygiene II!dehydration)
- II!USUALLY II!requires II!hospitalization
- II!Marked II!impairment II!in II!functioning II!of II!mood, II!cognition, II!perception, II!activity, II!and II!behavior. II!continuation II!phase II!of II!mania II!- II! II!Correct II!Answers II! II! II! II!1.) II!Last II!for II! 4 - 9 II!months 2.) II!Maintain II!medication II!adherence 3.) II!Psychoeducational II!teaching II!( II!social II!worker II!& II!family). 4.) II!Referrals II!s/s II!of II!serotonin II!syndrome II!- II! II!Correct II!Answers II! II! II! II!abdominal II!pain Diarrhea II!bloating Sweating Hyperpyrexia Tachycardia Elevated II!Blood II!Pressure Altered II!Mental II!State II!(delirium) Seizures Irrationality, II!mood II!swings, II!hostility Apnea II!and II!deat
II!drug-drug II!interactions II!for II!MAOI's II!- II! II!Correct II!Answers II! II! II! II!OTC II!allergy II!and II!cold II!meds; II!products II!that II!contain II!ephedrine
- II!narcotics
- tca
- II!amine II!precursors II!like II!levodopa
- II!tryptohan
- II!general II!anesthetics II!
- II!stimulants II!(amphetamines II!and II!cocaine) II!Foods II!to II!avoid II!while II!takingII!Monoamine II!Oxidase II!Inhibitors II!(MAOIs) II!- II! II!Correct II!Answers II! II! II! II!Foods II!High II!in II!Tyramine: II! Vegetables: II!over-ripe II!avocados, II!fermented II!bean II!curd, II!soybean II!paste, II!fava II!beans Fruits: II!over-ripe II!bananas II!and II!figsMeats: II!fermented/cured II!types II!like II!bologna, II!pepperoni, II!salami; II!chicken II!pate Cheeses: II!aged II!cheeses Drinks: II!chianti II!wine, II!imported II!beers Non-tyramine II!vasopressors: II!chocolate, II!ginseng, II!caffeinated II!drinks II!Triclyclic II!Antidepressants II!(TCA's)
- II!Amitriptyline II!(Elavil) II!- II! II!Correct II!Answers II! II! II! II!Action: II!TCAs II!inhibit II!the II!reuptake II!of II!Norepinephrine II!(NE) II!and II!Serotonin II!(5-HT)
- II!Sedating II!effects II!are II!due II!to II!the II!blockade II!of II!histamine II!receptors, II!causing II!anticholinergic II!side II!effects REMEMBER** II!TCAs II!need II!to II!be II!taken II! 10 - 14 II!days II!or II!longer II!before II!they II!begin II!to II!work. II!full II!effects II!in II! 4 - 8 II!weeks
Side II!effects: II!dry II!mouth, II!blurred II!vision, II!tavhycardia, II!constipation, II!urinary II!retention II!contraindications II!for II!TCA's II!- II! II!Correct II!Answers II! II! II! II!avoid II!Use II!with II!suicidal II!clients: II!TCAs II!are II!very II!toxic II!in II!overdose, II!carry II!a II!narrow II!therapeutic II!index, II!have II!rapid II!absorption. II!potential II!toxic II!side II!effects II!of II!TCA's II!- II! II!Correct II!Answers II! II! II! II!Dysrythmias Myocardial II!infarction Orthostatic II!Hypotension **Elderly II!patients II!are II!at II!risk II!for II!falls II!and II!cardiac II!complications **Cardiac II!workup II!needed II!before II!starting II!the II!drug **TCAs II!are II!more II!lethal II!in II!an II!overdose II!than II!SSRIs II!drug-drug II!interactions II!with II!TCA II!therapy II!- II! II!Correct II!Answers II! II! II! II!MAOIs Phenothiazines Barbiturates Disulfiram II!(Antabuse) Oral II!Contraceptives Anticoagulants Antihypertensives II!such II!as II!Clonidine II!or II!Reserpine Benzodiazepines Alcohol II!TCA II!avoid II!use II!in II!patients II!with II!hx II!of____ II!- II! II!Correct II!Answers II! II! II! II!Patient II!who II!has II!had II!a II!recent II!heart II!attack Narrow II!angle II!glaucoma History II!of II!seizures Women II!who II!are II!pregnant II!should II!not II!take II!TCAs
II!S/S II!of II!lithium II!toxicity II!- II! II!Correct II!Answers II! II! II! II!Early II!toxicity: II!1.5-2.0 II!mEq/L: GI II!upset, II!coarse II!hand II!tremor, II!confusion, II!hyper-irritable II!muscles, II!EKG II!changes, II!sedation, II!incoordination Advanced II!stage II!of II!toxicity II!2,0-2.5 II!mEq/L: acute II!giddiness, II!EEG II!changes, II!blurred II!vision, II!clonic II!muscle II!movements, II!dilute II!urine, II!seizures, II!stupor, II!severe II!hypotension, II!coma, II!death II!due II!to II!pulmonary II!complications II!side II!effects II!of II!lithium II!- II! II!Correct II!Answers II! II! II! II!LMNOP: Lithium II!side II!effects II!- Movement II!(tremor) Nephrogenic II!diabetes II!insipidus II!(ADH II!antagonist) hypOthyroidism Pregnancy II!problems II!mild II!to II!moderate II!lithium II!toxicity II!- II! II!Correct II!Answers II! II! II! II!• II!Diarrhea
- II!Vomiting
- II!Drowsiness
- II!Dizziness
- II!Hand II!tremor II!(coarse)
- II!Muscular II!weakness
- II!Lack II!of II!coordination II!key II!things II!to II!know II!while II!patient II!is II!on II!lithium II!therapy II!- II! II!Correct II!Answers II! II! II! II!** II!when II!sodium II!goes II!down II!lithium II!goes II!up** Patients II!can II!have II!salt II!in II!their II!diet II!to II!prevent II!the II!potential II!for II!toxicity II!best II!treatment II!choice II!for II!a II!patient II!that II!has II!rapid II!cycling II!disorder II!- II! II!Correct II!Answers II! II! II! II!anticonvulsant II!drugs
- II!more II!effective II!with II!no II!family II!hx II!of II!bipolar
II!Valoproate II!(Valproic II!Acid II!/ II!depakote) II!treats II!- II! II!Correct II!Answers II! II! II! II!acute II!mania, II!bipolar II!prophylaxis, II!mixed, II!and II!rapid-cycling II!bipolar II!illness, II!and II!seizure II!disorders II!side II!effects II!of II!valporate II!(depakote) II!- II! II!Correct II!Answers II! II! II! II!weight II!gain II!is II!common; II!sedation, II!GI II!upset II!(nausea, II!vomiting, II!diarrhea) II!is II!common II!rare II!but II!serious II!s/e II!of II!depakote II!- II! II!Correct II!Answers II! II! II! II!hepatotoxicity II!
- could II!be II!fatal II!(monitor II!liver II!functions; II! pancreatitis II!
- II!(monitor II!serum II!amylase II!levels; II! thrombocytopenia II!(bleeding/bruising)
- monitor II!platelets• Has II!been II!associated II!with II!women II!developing II!polycystic II!ovaries II!Carbamazepine II!(Tegretol) II!use II!in II!mental II!health II!- II! II!Correct II!Answers II! II! II! II!acute II!mania, II!mixed II!and II!rapid II!cycling II!mania II!S/E II!of II!Carbamazepine II!(Tegretol) II!- II! II!Correct II!Answers II! II! II! II!sedation, II!dizziness, II!fatigue, II!nausea severe: II!agranulocytosis II!or II!aplastic II!anemia II!(monitor II!CBC), II!Stevens II!Johnsons II!syndrome II! ** II!avoid II!in II!pregnancy II!bc II!it II!can II!cause II!craniofacial II!neural II!tube II!defect, II!and II!developmental II!delays II!in II!the II!newborns II!** II!Lamotrigine II!(Lamictal) II!- II! II!Correct II!Answers II! II! II! II!use: II!bipolar
headache drowsiness nausea constipation dry II!mouth, II!or II!increased II!salivation; vision II!problems fever, II!increased II!sweating. severe: II!agranulocytosis II!blood II!tests II!for II!clozapine II!therapy II!- II! II!Correct II!Answers II! II! II! II!initial II!blood II!test II!to II!check II!that II!you II!have II!a II!normal II!level II!of II!white II!blood II!cells II!before II!you II!first II!start II!on II!Clozapine. II! If II!this II!is II!OK II!and II!you II!begin II!treatment II!with II!Clozapine, II!you II!will II!need II!to II!have II!a II!blood II!test II!on II!day II! 3 II!of II!treatment II!and II!then II!every II!week II!for II! 18 II!weeks. II!antidepressant II!drugs II!- II! II!Correct II!Answers II! II! II! II!moa: II!increased II!availability II!of II!serotonin, II!Norepi., II!and II!dopamine. s/e: II!HTN, II!heart II!block, II!tachycardia, II!dizziness, II!sedation, II!apetite II!changes, II!ED, II!nausea, II!vomiting, II!dry II!mouth, II!urinary II!retention II!Serotonin II!Syndrome II!(medical II!emergency) II!- II! II!Correct II!Answers II! II! II! II!moa: II!overreaction II!of II!serotonin II!(5-HT) II!receptors II!caused II!by II!increase II!dose II!of II!medication II!or II!drug II!to II!drug II!reactions. drug-drug II!reactions: II!other II!antidepressants II!and II!tryptans II!SSRI's II!- II! II!Correct II!Answers II! II! II! II!drugs: II!citalopram, II!escitalopram, II!fluoxetine, II!setraline use: II!1st II!line II!tx II!for II!major II!depression II!disorders
moa: II!block II!serotonin II!reuptake II!at II!synapse s/e: II!insomnia, II!agitation, II!headaches, II!anorgasmia, II!hyponatremia II!Catharsis II!- II! II!Correct II!Answers II! II! II! II!a II!release II!of II!emotional II!tension II!hostility II!- II! II!Correct II!Answers II! II! II! II!verbal II!aggression II!that II!is II!expressed II!through II!verbal II!abuse, II!lack II!of II!cooperation, II!violation II!of II!rules II!or II!norms, II!threatening II!behavior II!continuum II!of II!anger II!and II!agression II!- II! II!Correct II!Answers II! II! II! II!1. II!feeling II!of II!vulnerability
- II!uneasiness
- II!anxiety
- II!anger
- II!agression
- II!violence II!PAST II!HISTORY II!OF II!VIOLENCE II!best II!predictor II!of II!future II!violence II!- II! II!Correct II!Answers II! II! II! II!what II!is II!the II!best II!predictor II!of II!future II!violence? II!Broset II!Violence II!Checklist II!- II! II!Correct II!Answers II! II! II! II!confusion, II!irritability, II!boisterousness, II!physically II!threatening, II!verbally II!threatening, II!attacking II!objects; II! scores II!aggression II!risk II!and II!is II!good II!risk II!indicator II!for II!up II!to II! 24 II!hours score II!of II! 1 - 2 II!- II!risk II!is II!moderate score II!of II!2+ II!- II!risk II!is II!very II!high II!Phases II!of II!aggression II!- II! II!Correct II!Answers II! II! II! II!1. II!triggering II!phase
*Sometimes II!a II!combination II!of II!the II!above II!meds II!are II!given *Given II!IM II!in II!psych II!emergency/crisis II!chronic II!aggression II!medications II!- II! II!Correct II!Answers II! II! II! II!Anticonvulsants: II!carbamazepine, II!valproic II!acid ß-blockers: II!propranolol 2nd II!generation II!antipsychotics Longer II!acting II!benzodiazepines II!such II!as II!clonazepam II!De-escalation II!techniques II!- II! II!Correct II!Answers II! II! II! II!-Maintain II!the II!patient's II!self-esteem II!and II!dignity.
- Maintain II!calmness II!(your II!own II!and II!the II!patient's).
- Assess II!the II!patient II!and II!the II!situation.
- Identify II!stressors II!and II!stress II!indicators.
- Respond II!as II!early II!as II!possible.
- Use II!a II!calm, II!clear II!tone II!of II!voice.
- Invest II!time.
- Remain II!honest.
- Establish II!what II!the II!patient II!considers II!to II!be II!his II!or II!her II!need.
- Be II!goal-oriented.
- Maintain II!a II!large II!personal II!space.
- Avoid II!verbal II!struggles.
- Give II!several II!options.
- Make II!clear II!the II!options.
- Utilize II!a II!nonaggressive II!posture.
- Use II!genuineness II!and II!empathy.
- Attempt II!to II!be II!confidently II!aware.
- Use II!verbal, II!nonverbal, II!and II!communication II!skills.
- Be II!assertive II!(not II!aggressive).
- Assess II!for II!personal II!safety.
II!Use II!of II!restraints II!- II! II!Correct II!Answers II! II! II! II!-requires II!physician II!order, II!can II!be II!initiated II!by II!nurse II!in II!emergency II!but II!need II!an II!order II!ASAP
- Physician II!must II!assess II!the II!patient II!within II!an II!hour II!of II!placement II!in II!seclusion II!or II!restraint II!Maintain II!personal II!dignity II!of II!the II!patient
- NEVER II!USED II!AS II!PUNISHMENT
- Maintain II!1:1 II!observation II!assessment II!when II!using II!restraints II!- II! II!Correct II!Answers II! II! II! II!Assess II!& II!meet II!basic II!needs II!of II!the II!patient II! When II!in II!restraints: II!Routinely II!release II!restraints II!for II!ROM II!Assess II!circulatory II!status II!of II!extremities II! Ensure II!elimination II!needs II!are II!met II!RN II!responsibility's II!for II!restraints II!- II! II!Correct II!Answers II! II! II! II!1. II!Documentation II!noting II!when II!restraints II!are II!initiated, II!least II!restrictive II!measures II!attempted II!& II!need II!for II!seclusion/restraint
- II!Perform II!baseline II!assessment II!every II!hour, II!document II!reason II!for II!continuing II!restraints/seclusion
- II!Ensure II!documentation II!of II!assessment II!is II!completed II!every II! 15 II!minutes
- II!Assess II!readiness II!for II!discontinuation II!of II!S/R: II!inform II!patient II!of II!reason II!for II!S/R II!and II!criteria II!for II!release 5.Document II!in II!when II!restraints II!are II!discontinued II!what II!does II!the II!nurse II!need II!to II!document II!for II!aggression II!nd II!s/r II!use II!- II! II!Correct II!Answers II! II! II! II!Detailed II!description II!of II!aggression/behaviors Nursing II!interventions II!and II!de-escalation II!attempts Patient II!response, II!& II!evaluation II!of II!interventions Who II!was II!called II!to II!assess II!patient, II!order II!medications, II!seclusion/restraints II!psychosis II!- II! II!Correct II!Answers II! II! II! II!disorganized II!thoughts II!and II!distorted II!perception II!of II!reality. II!
- II!usually II!have II!loss II!of II!function II!and II!lack II!of II!insight II!and II!do II!not II!realize II!their II!perception II!of II!reality II!is II!distorted.
