ATI CMS MENTAL HEALTH EXAM REVIEW | QUESTIONS AND
VERIFIED ANSWERS | ALREADY GRADED A+ | LATEST EXAM
LOC - ALERT
patient is responsive
opens eyes spontaneously
answers questions appropriately
LOC - LETHARGIC
patient can open eyes and respond to questions
falls asleep easily
LOC - OBTUNDED
patient responds to light shaking
is confused
slow to respond
LOC - STUPOROUS
patient barely responds to painful stimuli
example
rubbing sternum
LOC - COMATOSE
patient is unresponsive
abnormal posturing may be present
DECORTICATE POSTURING
arms flexed/internally rotated
legs extended/internally rotated
,DECEREBRATE POSTURING
head arched back
arms/legs extended
AUTONOMY
patient has the right to make their own decisions even if not in their best
interest
BENEFICENCE
do what is best for the patient
do good
FIDELITY
keep your promises
loyalty/faithfulness
JUSTICE
provide fairness in care and allocation of resources
NONMALEFICENCE
do no harm
VERACITY
tell the truth
PATIENT RIGHTS - REFUSAL OF TREATMENT
even patients who are involuntarily admitted have the right to refuse
treatment
PATIENT RIGHTS - CONFIDENTIALITY
HIPAA states that health information cannot be released without patient's
permission
client's right to privacy continues even after death
CONFIDENTIALITY - NURSING ACTIONS
if someone calls to get an update, suggest they reach out to the patient's
family
,if you overhear a conversation in a public space, take action to stop the
violation
PATIENT RIGHTS - MANDATORY REPORTING
nurses are required to report suspicion of abuse
warn/protect third parties who are at risk for harm
INFORMED CONSENT - PROVIDER RESPONSIBILITIES
communicate purpose of procedure
provide a complete description of procedure in patient's primary language
(use interpreter if needed)
explain risks vs. benefits
describe other options to treat condition
INFORMED CONSENT - NURSE/RN RESPONSIBILITIES
make sure provider gave patient appropriate information regarding
procedure
ensure that patient is competent to give informed consent
have patient sign consent document
notify provider if patient has more questions or doesn't understand
information provided
RESTRAINTS - TYPES
Physical
- vest
- belt
- mitten
Chemical
- sedative Rx
- antipsychotic Rx
RESTRAINTS - ALTERNATIVES
, provide verbal interventions
diversions
calm/quiet environment
RESTRAINTS - PRESCRIPTIONS
MUST BE IN WRITING
prescription must be rewritten every 24 hours
in an emergency situation, a nurse may use restraints, but must obtain a
written prescription per facility policy (usually within 15-30 minutes)
RESTRAINTS - TIME LIMITS
Adults
4 hours
Ages 9 - 17
2 hours
Ages 8 and Under
1 hour
RESTRAINTS - DOCUMENTATION
complete every 15-30 minutes
include the following:
- precipitating event
- alternative interventions attempted
- time treatment began
- medication(s) administered
- patient assessment (current behavior, VS, pain)
- patient care provided (food, toileting)
RESTRAINTS - DISCONTINUATION
restraints can be discontinued when patient can follow nurse's directions
UNINTENTIONAL TORTS
VERIFIED ANSWERS | ALREADY GRADED A+ | LATEST EXAM
LOC - ALERT
patient is responsive
opens eyes spontaneously
answers questions appropriately
LOC - LETHARGIC
patient can open eyes and respond to questions
falls asleep easily
LOC - OBTUNDED
patient responds to light shaking
is confused
slow to respond
LOC - STUPOROUS
patient barely responds to painful stimuli
example
rubbing sternum
LOC - COMATOSE
patient is unresponsive
abnormal posturing may be present
DECORTICATE POSTURING
arms flexed/internally rotated
legs extended/internally rotated
,DECEREBRATE POSTURING
head arched back
arms/legs extended
AUTONOMY
patient has the right to make their own decisions even if not in their best
interest
BENEFICENCE
do what is best for the patient
do good
FIDELITY
keep your promises
loyalty/faithfulness
JUSTICE
provide fairness in care and allocation of resources
NONMALEFICENCE
do no harm
VERACITY
tell the truth
PATIENT RIGHTS - REFUSAL OF TREATMENT
even patients who are involuntarily admitted have the right to refuse
treatment
PATIENT RIGHTS - CONFIDENTIALITY
HIPAA states that health information cannot be released without patient's
permission
client's right to privacy continues even after death
CONFIDENTIALITY - NURSING ACTIONS
if someone calls to get an update, suggest they reach out to the patient's
family
,if you overhear a conversation in a public space, take action to stop the
violation
PATIENT RIGHTS - MANDATORY REPORTING
nurses are required to report suspicion of abuse
warn/protect third parties who are at risk for harm
INFORMED CONSENT - PROVIDER RESPONSIBILITIES
communicate purpose of procedure
provide a complete description of procedure in patient's primary language
(use interpreter if needed)
explain risks vs. benefits
describe other options to treat condition
INFORMED CONSENT - NURSE/RN RESPONSIBILITIES
make sure provider gave patient appropriate information regarding
procedure
ensure that patient is competent to give informed consent
have patient sign consent document
notify provider if patient has more questions or doesn't understand
information provided
RESTRAINTS - TYPES
Physical
- vest
- belt
- mitten
Chemical
- sedative Rx
- antipsychotic Rx
RESTRAINTS - ALTERNATIVES
, provide verbal interventions
diversions
calm/quiet environment
RESTRAINTS - PRESCRIPTIONS
MUST BE IN WRITING
prescription must be rewritten every 24 hours
in an emergency situation, a nurse may use restraints, but must obtain a
written prescription per facility policy (usually within 15-30 minutes)
RESTRAINTS - TIME LIMITS
Adults
4 hours
Ages 9 - 17
2 hours
Ages 8 and Under
1 hour
RESTRAINTS - DOCUMENTATION
complete every 15-30 minutes
include the following:
- precipitating event
- alternative interventions attempted
- time treatment began
- medication(s) administered
- patient assessment (current behavior, VS, pain)
- patient care provided (food, toileting)
RESTRAINTS - DISCONTINUATION
restraints can be discontinued when patient can follow nurse's directions
UNINTENTIONAL TORTS
