Restraints

Which of the following criteria would be used to determine that a patient no longer needs restraints/seclusion:

The reason/clinical justification for restraints/seclusion no longer exists.

The RN is caring for a patient that may require nonviolent physical restraints. Place the following options in orders of LEAST to MOST restrictive:

Item 1 Soft wrist restraint Your Answer 3 Correct Answer 3 Item 2 Mitt Your Answer 2 Correct Answer 2 Item 3 Patient companion Your Answer 1 Correct Answer 1

It is not the type or the nature of the chosen device or method, but the INTENT OF its USE that determines it to be a restraint.

Your Answer True

All of the following are acceptable non-physical intervention skills to use instead of applying restraints EXCEPT:

Putting the tray on the Geri Chair to keep the patient from getting up

For a patient in violent restraints, a face to face assessment of the patient must be performed by the prescriber every 24 hours and before writing a new order.

Your Answer True

An intubated patient has soft limb wrist restraints ordered for airway protection. The RN removes the restraints at the time of extubation. Over the next 2 hours, the patient is continually pulling at IV lines, nasal cannula, and urinary catheter. After several attempts to redirect the patient, the RN reapplies the soft limb restraints. This does not require a new restraint order because it is still related to the patient's plan of care.

Your Answer False

Orders for restraint or seclusion can be written as a standing order or as needed (prn):

Your Answer False

A 46-year-old male patient presents to the ED as a level 2 trauma, motor vehicle accident. He is belligerent and smells of alcohol. Still secured to the backboard, he is swinging and spitting at staff who are attempting to evaluate injuries. The physician approves application of ankle and wrist restraints. The restraint order appropriate for this scenario is:

Your Answer Violent Restraints Order

Restraints must be secured to a part of the bed frame that moves with the patient to prevent injury during position change.

Correct Answer True

40 yr. old male, diabetic patient admitted with pneumonia is yelling in his room. The staff rushed to the room due to the yelling and finds the patient threatening and swinging at staff whenever they try to come near him. A code violet (Ohio) is called and the team ends up putting the patient in 4 point locking limb restraints. Labs are ordered, and it was identified that the glucose reading was 29. The staff intervened appropriately and the repeat blood sugar check was 90. The patient was calm and unaware of his actions after the blood sugar returned to within normal limits. The restraints were discontinued. When the nurse called the provider, which order would be appropriate for the scenario:

Correct Answer Violent Restraints Order

When caring for a patient in violent restraints, documentation of offering toileting/hygiene and nutrition/hydration should occur at a minimum of every ___hour/s:

Your Answer 1 hour

When a patient is in violent restraints, remove and reapply restraints for ROM and repositioning of extremity every ___ hour/s.

Your Answer 2 hours

Which of the following is considered a physical restraint? (select all that apply):

Your Answer All four side rails raised up Your Answer A sheet tightly tucked into the bed so the patient can't move Your Answer Use of a net bed

Before removing violent restraints, the RN must understand:

Your Answer All of the above

Which of the following statements describe the importance of annual restraint education and training?

Your Answer All of the above

The RN is caring for a 20-year-old patient in violent restraints who is continually monitored by direct observation. The patient's condition is monitored and documented by the assigned trained staff member at regular intervals not to exceed 15 minutes for the following: (SELECT ALL THAT APPLY)

Your Answer Circulatory Status Your Answer Patient behavior Your Answer Signs of respiratory distress

A patient is in restraints according to the order and reason written, but is becoming more verbally and physically agitated and violent with each passing moment, you should:

Your Answer Contact the prescriber to relay the findings

Alternative Measures to restraints include the following EXCEPT:

Your Answer Threatening the patient with the use of restraint for non-compliance

Patients are not restrained in the prone position; the exception being for a brief time in the transitional hold.

Your Answer True

The order for nonviolent restraints is valid for the duration of the episode of care or until the reason for the restraint ceases to exist:

Your Answer True

Transitional Hold" is defined by the Ohio Department of Mental Health as a brief physical restraint of an individual face-down for the purpose of quickly and effectively gaining physical control of that individual, or prior to transport to enable the individual to be safely transported.

Your Answer True

Upon initiation of violent restraints/seclusion, the physician or specially trained RN must complete a face to face evaluation within 1 hour of implementation:

Your Answer True

A 96 yr. old female is admitted with UTI. She is oriented to name, but disoriented to place, time, and situation. She has pulled her IV out 3 times despite the room being across from the nurses' station and increasing rounds. It was decided to put a sitter with the patient, but that also failed as an intervention to keep the patient from pulling out the IV. Which restraint order is appropriate for the scenario:

Your Answer Nonviolent order with mitten restraints

The RN must document which of the following assessments and interventions of a patient in non-violent restraints a minimum of every 2 hours (select all that apply)

Your Answer Circulation Check Your Answer Respiratory Status Your Answer Release of restraint (one at a time) for range of motion, repositioning, and reapplication Your Answer Patient's emotional well-being/response to restraint Your Answer Skin integrity of restrained extremity Your Answer Vascular status

Hospitals must report which of the following deaths associated with restraint or seclusion directly to their CMS Regional Office (RO) no later than the close of business on the next business day following knowledge of the patient's death- excluding those in which only 2-point soft wrist restraints were used and the patient was not in seclusion within 24 hours of their death (select all that apply)

Your Answer If a patient expires while in restraints. Your Answer Death within 24 hours after restraints have been removed. Your Answer Death within 24 hours after being removed from seclusion.

A patient's condition deteriorates and he is intubated. A STAT CT brain is ordered. While in the CT department, the patient begins reaching for the ET tube. The nurse accompanying the patient applies wrist restraints and contacts the prescriber for orders. The restraint order appropriate for this scenario is:

Your Answer Non-Violent Restraints Order

Your patient has pulled out two previous nasogastric tubes. You receive an order to place another nasogastric tube. The patient is alert, restless and picking at his nose. You tried alternative measures but nothing is working. The decision is made to apply bilateral soft wrist restraints. What type of restraint should be ordered?

Your Answer Non-violent restraints

Behaviors that may trigger circumstances that require the use of a restraint include (select all that apply)

Your Answer Patient at risk for discontinuation of lines/tubes Your Answer Patient at risk for discontinuation of artificial airway Your Answer Safety due to developmental delay/cognitive limitation Your Answer Documented situations in which the patient is in danger of hurting him/herself, staff, or others