UNIT 6 EXAM- HEALTH CARE
COMPETENCIES II- INTRO TO NURSING
EXAM QUESTIONS WITH CORRECT
ANSWERS
What occurs during post-fall management - Answer--debriefing: what happened, how
did it happen, why did it happen, were appropriate interventions in place, could this
have been avoided, are there any changes for the care plan, reassess the patient
What is the role of a nurse when a fall occurs? - Answer--Get help
-Assess the patient: vitals, injuries, ROM, pain and bleeding
-DO NOT MOVE THEM UNTIL ASSESSMENTS ARE COMPLETE
- Can the patient be treated at the facility
-Notify family and HCP
- Fill out incident report
- Institute fall precautions if not already in place
What are the components of a fall risk assessment upon admission? - Answer-- Head to
toe assessment
- past history of falls
- medication list
- cognitive function
- urinary pattern or incontinence
What is the role of UAP when a fall occurs? - Answer-- call for help
-DO NOT GET THE PATIENT UP
What is a physical restraint and list types of restraints - Answer-A physical restraint is
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.
Types of Physical Restraints:
- Behavioral: used in ER or psych unit: controls aggressive violent behavior, or behavior
that is dangerous to oneself/others
- Medical/Surgical: used in acute or LTC used in care management for a patient who is
exhibiting behaviors interfering with treatment: pulling out IV or cath
- Forensic: physical restraints applied to patients who have been leagally detained
(handcuffs)
, What is a chemical restraint? - Answer-Medications such as:
-anxiolytics or sedatives used to manage a patients behavior that is not a standard
treatment or dosage for the patients condition
What is seclusive restraint? - Answer-involuntary confinement of a patient alone in a
room or area from which a patient is physically prevented from leaving
What is not considered a restraint? - Answer-- orthopedically prescribed devices (cast
or brace)
- surgical dressings or bandages
- protective helmets
- physically withholding patient during treatment to prevent harm to patient
What are acceptable uses of a restraint? - Answer-- used to reduce risk of patient injury
from falls
- used to prevent interruption of therapy
- used to prevent removal of life support equipment
- used to reduce risk of injury to others
List types of restraints from least restrictive to most restrictive - Answer-Least :
- Vail bed
- Side rails
- enclosure beds
- mitt
- freedom sleeves
- elbow pads
- soft wrist
- lap or waist belt
- vest
Most
*Remember to have two fingers between restraint and patient
What are the things the nurse needs to do prior to placing a restraint? - Answer--
Alternative or distractions
- Knowledge of facilities policies and procedures
- Obtain physician orders (if possible)
- Document
- Educate patient and family of what to expect and the purpose
- Informed consent
- Take vitals
- Reassess
- Weigh risks of using vs. not using restraints
- Get input from other team members
COMPETENCIES II- INTRO TO NURSING
EXAM QUESTIONS WITH CORRECT
ANSWERS
What occurs during post-fall management - Answer--debriefing: what happened, how
did it happen, why did it happen, were appropriate interventions in place, could this
have been avoided, are there any changes for the care plan, reassess the patient
What is the role of a nurse when a fall occurs? - Answer--Get help
-Assess the patient: vitals, injuries, ROM, pain and bleeding
-DO NOT MOVE THEM UNTIL ASSESSMENTS ARE COMPLETE
- Can the patient be treated at the facility
-Notify family and HCP
- Fill out incident report
- Institute fall precautions if not already in place
What are the components of a fall risk assessment upon admission? - Answer-- Head to
toe assessment
- past history of falls
- medication list
- cognitive function
- urinary pattern or incontinence
What is the role of UAP when a fall occurs? - Answer-- call for help
-DO NOT GET THE PATIENT UP
What is a physical restraint and list types of restraints - Answer-A physical restraint is
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.
Types of Physical Restraints:
- Behavioral: used in ER or psych unit: controls aggressive violent behavior, or behavior
that is dangerous to oneself/others
- Medical/Surgical: used in acute or LTC used in care management for a patient who is
exhibiting behaviors interfering with treatment: pulling out IV or cath
- Forensic: physical restraints applied to patients who have been leagally detained
(handcuffs)
, What is a chemical restraint? - Answer-Medications such as:
-anxiolytics or sedatives used to manage a patients behavior that is not a standard
treatment or dosage for the patients condition
What is seclusive restraint? - Answer-involuntary confinement of a patient alone in a
room or area from which a patient is physically prevented from leaving
What is not considered a restraint? - Answer-- orthopedically prescribed devices (cast
or brace)
- surgical dressings or bandages
- protective helmets
- physically withholding patient during treatment to prevent harm to patient
What are acceptable uses of a restraint? - Answer-- used to reduce risk of patient injury
from falls
- used to prevent interruption of therapy
- used to prevent removal of life support equipment
- used to reduce risk of injury to others
List types of restraints from least restrictive to most restrictive - Answer-Least :
- Vail bed
- Side rails
- enclosure beds
- mitt
- freedom sleeves
- elbow pads
- soft wrist
- lap or waist belt
- vest
Most
*Remember to have two fingers between restraint and patient
What are the things the nurse needs to do prior to placing a restraint? - Answer--
Alternative or distractions
- Knowledge of facilities policies and procedures
- Obtain physician orders (if possible)
- Document
- Educate patient and family of what to expect and the purpose
- Informed consent
- Take vitals
- Reassess
- Weigh risks of using vs. not using restraints
- Get input from other team members
