NSG 106 Chapter 4 Safety/Restraints

A toddler is to undergo a procedure for which the child needs to be restrained with a mummy restraint . The procedure is expected to take about 10 minutes . Which approach might the nurse suggest as an alternative to using a mummy restraint ?

Therapeutic holding

Which recommendations should be included in a teaching plan for preventing falls in the home ?

Use a night light . , Remove clutter from walkways . , Keep electrical and telephone cords against the wall and out of walkways . , Avoid climbing on a chair or table to reach items that are too high to reach .

frame

Use a quick-release knot to tie the restraint to the bed _____, not side rail

The nurse is caring for a client with bilateral soft extremity restraints . The client is confused and tried to get out of bed , pulling out the urinary catheter which has been reinserted . Which is the best action by the nurse ?

Use a safety monitoring device .

therapeutic holding

What is the alternative approach for temporary restraint when mummy restraint is not working?

quick release knot

What kind of knot needs to be tied with restraints?

least, earliest

When it is necessary to apply a restraint, the nurse should use the _______ restrictive method and should remove it at the ______ possible time.

Primary Care provider

Who do restraints have to be ordered by?

The Joint Commission

Who establishes guidelines to promote patient safety ?

2 fingers

Wrap the restraint snugly around the patient's arm, but make sure that ____ fingers can easily fit under the restraint when using elbow restraints

Physical

_______ restraints should be considered as a last resort after other care alternatives have been unsuccessful

restraint

any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely; a drug or medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition

Safety event report

documentation that describes any occurrence that results in injury or has the potential to result in injury, to a patient, employee, or visitor; also called a variance, occurrence, or incident report

A nurse is caring for a client at risk for falls who does not have access to an activated bed or chair alarm . How often should the nurse assess this client ?

every 60 minutes

The nurse is caring for an adult who requires IV fluids but continues to pull at the IV site and tubing . The adult child tries to calm the client , without success . Which short - term restraints should the nurse use to control the adult's movement during the procedure ?

extremity restraint

After applying a restraint to a client , the nurse is required to stay with the client while it in use . Which type of restraint has the nurse applied ?

mummy restraint

The nurse is caring for a hysterical child who requires assessment of a dog bite near the eye . The parent is in emotional state that is not appropriate for helping to immobilize the child . The nurse should implement which restraints to best enable the health care provider to examine the client's injury ?

mummy restraint

The nurse has finished a discussion with an older adult client about dangers in the home . The nurse recognizes that the instruction was effective when the client identifies which common risks in the home ? Select all that apply

polypharmacy clutter extension cords

The nurse is caring for an older adult for whom the health care provider has prescribed an elbow restraint . The elbow restraint should not impede circulation . Which pulse will the nurse assess to decide if circulation is compromised ?

radial

cloth extremity restraints

restraints that immobilize one or more extremities... indicated after other measures have failed to prevent a patient from removing therapeutic devises like IV, endotracheal tubes, oxygen

The nurse is caring for an infant for whom the health care provider has prescribed a mummy restraint . The infant's parent asks the nurse what will be used to implement the mummy restraint on the infant . What is the best response by the nurse ?

sheet or blanket

situational assessment

the process of looking at how the circumstances surrounding an event influence people responding to that event... assess ABCs, patients level of consciousness, orientation, and speech

true

true/false Exercise programs, such as muscle strengthening, balance training, and walking plans, decrease falls and fall-related injuries

The nurse is preparing to administer a waist restraint to a client in a wheelchair . Which method of securing the restraint is appropriate

tying the restraint behind the chair

The charge nurse is observing a new nurse care for a client who is at high risk for falls . Which actions by the new nurse would require the charge nurse to intervene ? MC

waiting outside of the closed bathroom door while the client uses the toilet

A nurse is counseling an older adult client on fall prevention in the home before the client is discharged from the hospital . Which action should the nurse recommend to the client ?

" Consult with your health care provider about beginning an exercise program . "

The nurse cares for a client who is postoperative after an abdominal surgery . Which is the most important statement for the nurse to use in teaching this client ?

" Use the call bell for any needs and wear nonslip footwear . "

wrinkles, fist

-Ensure that waist restraint is not too tight and has no _______ -insert _____ between restraint and patient to ensure that breathing is not constricted. Assess respirations after restraint is applied

waist restraint

-applied to patients torso over their clothes -patient can move extremities but cannot get out of the chair or bed -pose threat for potential risk for asphyxia death -assess torso for any wounds or therapeutic devices -assess patients respiratory effort, if applied incorrectly the waist restraint can restrict the patient's ability to breathe

situational assessment in the home

-assess for adequate lighting -objects on the floor, presence of wires or cords, objects on steps, loose/torn carpets -working smoke detectors -presence of space heaters -method used to store medications, cleaning products, insecticides, and corrosives

What to do if a patient experiences a fall?

-assess patients condition -notify patients primary care provider -follow through with any orders from primary care provider like x-rays and CTs -evaluate circumstances of the fall and the patient's environment and institute appropriate measures to prevent further incidents -document assessment and complete a safety event report per facility policy

primary causes of falls include

-change in balance or gait -muscle weakness -dizziness, syncope, vertigo -cardiovascular changes/ postural hypotension -change in vision or vision impairment -physical environment/environmental hazards -acute illness -neurologic disease, dementia or depression -language disorders that impair communication -polypharmacy

What to do when skin breakdown is noted on the elbow in an elbow restraint?

-ensure that restraints are being removed routinely for at least 30 min and skin inspection is done -if restraint is still needed, a padded dressing should be applied under the elbow restraint

elbow restraints

-generally used on infants and children -prevent patient from bending the elbows and reaching incisions or therapeutic devices -inspect the arm where the restraint will be applied... baseline skin condition should be established for comparison at future assessments while the restraint is in place -assess capillary refill and proximal pulses in the arm to which the restraint is to be applied

When does a fall risk assessment need to occur?

-on admission to the facility -during an initial home visit -following a change in the patients condition -after a fall -when the patient is transferred

therapeutic holding

-secure, comfortable, temporary holding position that provides close physical contact with the parent or caregiver for 30 min or less

negative outcomes of retraints

-skin breakdown -contractures -incontinence -depression -delirium -anxiety -aspiration -respiratory difficulties -death

The nurse is caring for a 2 - year - old child for whom elbow restraints have been prescribed . The nurse should remove the restraints and assess the child every how many hour ( s ) ?

1

The nurse is preparing to apply prescribed extremity restraints to a client's ankles . Place in order the steps of the procedure the nurse should perform . Use all options .

1 ) Explain rationale for use to the client and family . 2 ) Pad bony prominences . 3 ) Wrap the restraint around the client's ankle and secure it with hook - and - loop fastener straps . 4 ) Ensure that two fingers fit between the restraint and the client's skin . 5 ) Position limbs in normal anatomic position . 6 ) Secure restraints to the bed frame with quick - release knots

The nurse must apply a mummy restraint to a small child . Place the steps in the correct order . Use all options .

1 ) Secure a prescription from the health care provider 2 ) Explain the reason for use to the client and family . 3 ) Open the blanket or sheet and place the child on the blanket . 4 ) Position the child's right arm alongside the body and pull the right side of the blanket tightly over the child's right shoulder and chest . 5 ) Secure the blanket under the right side of the child's body . 6 ) Fold the lower part of the blanket up and pull over the child's body .

The nurse is caring for a client who has been prescribed extremity restraints . Which action must be documented by the nurse ?

: the alternative measures attempted before applying the restraints

24 hours

A physician or licensed independent practitioner must reevaluate and asses the patient every ___ hours

24

After ____ hours, before writing a new order for the use of restraint or seclusion for the management of violent or self-destructive behavior, a physician or other licensed independent practitioner who is responsible for the care of the patient must see and assess the patient.

failed, documented

Alternatives to restraints and less-restrictive interventions must have been implemented and ________. All alternatives used must be _______. Patients family must be consulted when the decision is made to use restraints

mummy restraint

Appropriate for short-term restraint of infant or small child. Uses a blanket to wrap around child like a mummy

The nurse is caring for an adult client on prescribed get out of bed despite instructions to remain in bed . Which initial interventions is bed rest who repeatedly attempts to appropriate ?

Assess for the need to urinate

The nurse in a critical care unit is caring for a child who is restrained with elbow restraints during a procedure . Which intervention should take priority ?

Assess the circulation to the client's fingers and hands .

The nurse is caring for a combative , confused client that has been prescribed soft wrist restraints . When administering soft wrist restraints to the client , which action by the nurse is most appropriate ?

Assess the client's need for fluids and toileting every 2 hours .

circulation

Before application of an extremity restraint, assess for adequate ________ in the extremity to which the restrain is to be applied, including capillary refill and proximal pulses

risk

Benefit gained from using restraints must outweigh the known _____ for that patient

The older adult client is moving to another apartment . The nurse should encourage the client's family to take which action to reduce the older adult's risk of falling in the new home ?

Clear clutter in the walkways of the new home .

The nurse considers applying restraints to an agitated client . Which actions does the nurse take ?

Dim the lights and speak softly about something the client enjoys . "

A nurse is implementing measures as alternatives to using restraints . When implementing the client's plan of care , the nurse would anticipate the need to check on the client at which frequency ?

Every 1 to 2 hours

two fingers

For an extremity restraint, make sure that ___ fingers can be inserted between the restraint and patients extremity

A nurse is caring for a client who is wearing a waist restraint . Which intervention by the nurse would be most appropriate to ensure that the client's breathing is not restricted ?

Insert the fist between the restraint and the client .

shoulder, wrist

Measure the distance from the patients _______ to ______ to determine the appropriate size of elbow restraint to apply

The nurse is caring for an older adult with dementia for whom the health care provider has prescribed a waist restraint . What should the nurse do immediately before applying the waist restraint ?

Pad bony prominences

The nurse is assigned a client for whom an elbow restraint is prescribed . Which general principles of correct placement of the elbow restraint will the nurse follow ? Select all that apply .

Pad bony prominences . , Ensure the restraint is the correct size for the client , Confirm the restraint does not extend below the wrist or place pressure on the axilla

hour

Patients vital signs must be assessed and the medical patient must be visually observed every _____ or according to facility policy

2 hours

Personal needs must be met. Provide fluids, nutrition, and toileting assistance every ____ hours

nurse is preparing an inservice program for a group of staff nurses about ways to minimize restraint use on the unit . The nurse plans to address the risks associated with physical restraint use . Which risk would the nurse include ? Select all that apply .

Pressure injuries , Contractures Delirium Falls

The nurse is caring for a client with Alzheimer dementia who lives with an adult child at home and has started to wander . The adult child asks , " What can I do to keep my parent safe ? " What are the best instruction ( s ) by the nurse ? Select all that apply .

Provide frequent reorientation . , Increase the parent's social interaction . , Ensure the parent engages in regular exercise .

The nurse is caring for a middle - aged adult who has been prescribed elbow restraints . The nurse observes that when the restraints are removed , the client cries and reports pain in the elbow . What is the best action by the nurse ?

Remove restraints more frequently and perform range of motion ( ROM ) .

2 hours

Skin integrity must be assessed and range or motion exercises provided every ___ hours

nurse cares for a client wearing a waist restraint . Which client action causes the nurse to change restraint types ?

The client continually tries to move from head of the bed toward the foot of the bed .

The nurse is caring for a violent client who has been wearing a waist restraint for 23 hours . A family member asks if the client will continue to wear the waist restraint . What is the best response by the nurse ?

The health care provider will see the client and assess whether the restraint prescription should be renewed . "