UNIT 6 EXAM- HEALTH CARE
COMPETENCIES II- INTRO TO NURSING
EXAM QUESTIONS WITH CORRECT
ANSWERS
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
What are some alternatives to a restraint? - Answer-- Companionship or supervision
- distraction activities: folding towels
- place patient near the nurses station
- exercise/ walking schedules
- offer food, fluids, movement and toileting frequently
- bed and chair alarms
- use calm simple statements
- promote relaxation and sleep
- provide visual and auditory stimuli
- hide their IV and other lines
- evaluate medications and assess the patient
COMPETENCIES II- INTRO TO NURSING
EXAM QUESTIONS WITH CORRECT
ANSWERS
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
What are some alternatives to a restraint? - Answer-- Companionship or supervision
- distraction activities: folding towels
- place patient near the nurses station
- exercise/ walking schedules
- offer food, fluids, movement and toileting frequently
- bed and chair alarms
- use calm simple statements
- promote relaxation and sleep
- provide visual and auditory stimuli
- hide their IV and other lines
- evaluate medications and assess the patient
