ATI CMS EXAM REVIEW - MENTAL HEALTH
Study online at https://quizlet.com/_68mi41
1. LOC - ALERT patient is responsive
opens eyes spontaneously
answers questions appropriately
2. LOC - LETHARGIC patient can open eyes and respond to questions
falls asleep easily
3. LOC - OBTUNDED patient responds to light shaking
is confused
slow to respond
4. LOC - STU- patient barely responds to painful stimuli
POROUS
*example*
rubbing sternum
5. LOC - COMATOSE patient is unresponsive
abnormal posturing may be present
6. DECORTICATE arms flexed/internally rotated
POSTURING
legs extended/internally rotated
, ATI CMS EXAM REVIEW - MENTAL HEALTH
Study online at https://quizlet.com/_68mi41
7. DECEREBRATE head arched back
POSTURING
arms/legs extended
8. AUTONOMY patient has the right to make their own decisions even if not in their best interest
9. BENEFICENCE do what is best for the patient
*do good*
10. FIDELITY keep your promises
loyalty/faithfulness
11. JUSTICE provide fairness in care and allocation of resources
12. NONMALEFI- do no harm
CENCE
13. VERACITY tell the truth
14. PATIENT RIGHTS even patients who are involuntarily admitted have the right to refuse treatment
- REFUSAL OF
TREATMENT
15. PATIENT RIGHTS HIPAA states that health information cannot be released without patient's per-
- CONFIDENTIALI- mission
TY
client's right to privacy continues even after death
, ATI CMS EXAM REVIEW - MENTAL HEALTH
Study online at https://quizlet.com/_68mi41
16. CONFIDENTIALI- if someone calls to get an update, suggest they reach out to the patient's family
TY - NURSING
ACTIONS if you overhear a conversation in a public space, take action to stop the violation
17. PATIENT RIGHTS - nurses are required to report suspicion of abuse
MANDATORY RE-
PORTING warn/protect third parties who are at risk for harm
18. INFORMED CON- communicate purpose of procedure
SENT -
PROVIDER RE- provide a complete description of procedure in patient's primary language (use
SPONSIBILITIES interpreter if needed)
explain risks vs. benefits
describe other options to treat condition
19. INFORMED CON- make sure provider gave patient appropriate information regarding procedure
SENT -
NURSE/RN RE- ensure that patient is competent to give informed consent
SPONSIBILITIES
have patient sign consent document
notify provider if patient has more questions or doesn't understand information
provided
20. RESTRAINTS - *Physical*
TYPES - vest
- belt
- mitten
*Chemical*
, ATI CMS EXAM REVIEW - MENTAL HEALTH
Study online at https://quizlet.com/_68mi41
- sedative Rx
- antipsychotic Rx
21. RESTRAINTS - AL- provide verbal interventions
TERNATIVES
diversions
calm/quiet environment
22. RESTRAINTS - *MUST BE IN WRITING*
PRESCRIPTIONS
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)
23. RESTRAINTS - *Adults*
TIME LIMITS 4 hours
*Ages 9 - 17*
2 hours
*Ages 8 and Under*
1 hour
24. RESTRAINTS - complete every 15-30 minutes
DOCUMENTA-
TION *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)
Study online at https://quizlet.com/_68mi41
1. LOC - ALERT patient is responsive
opens eyes spontaneously
answers questions appropriately
2. LOC - LETHARGIC patient can open eyes and respond to questions
falls asleep easily
3. LOC - OBTUNDED patient responds to light shaking
is confused
slow to respond
4. LOC - STU- patient barely responds to painful stimuli
POROUS
*example*
rubbing sternum
5. LOC - COMATOSE patient is unresponsive
abnormal posturing may be present
6. DECORTICATE arms flexed/internally rotated
POSTURING
legs extended/internally rotated
, ATI CMS EXAM REVIEW - MENTAL HEALTH
Study online at https://quizlet.com/_68mi41
7. DECEREBRATE head arched back
POSTURING
arms/legs extended
8. AUTONOMY patient has the right to make their own decisions even if not in their best interest
9. BENEFICENCE do what is best for the patient
*do good*
10. FIDELITY keep your promises
loyalty/faithfulness
11. JUSTICE provide fairness in care and allocation of resources
12. NONMALEFI- do no harm
CENCE
13. VERACITY tell the truth
14. PATIENT RIGHTS even patients who are involuntarily admitted have the right to refuse treatment
- REFUSAL OF
TREATMENT
15. PATIENT RIGHTS HIPAA states that health information cannot be released without patient's per-
- CONFIDENTIALI- mission
TY
client's right to privacy continues even after death
, ATI CMS EXAM REVIEW - MENTAL HEALTH
Study online at https://quizlet.com/_68mi41
16. CONFIDENTIALI- if someone calls to get an update, suggest they reach out to the patient's family
TY - NURSING
ACTIONS if you overhear a conversation in a public space, take action to stop the violation
17. PATIENT RIGHTS - nurses are required to report suspicion of abuse
MANDATORY RE-
PORTING warn/protect third parties who are at risk for harm
18. INFORMED CON- communicate purpose of procedure
SENT -
PROVIDER RE- provide a complete description of procedure in patient's primary language (use
SPONSIBILITIES interpreter if needed)
explain risks vs. benefits
describe other options to treat condition
19. INFORMED CON- make sure provider gave patient appropriate information regarding procedure
SENT -
NURSE/RN RE- ensure that patient is competent to give informed consent
SPONSIBILITIES
have patient sign consent document
notify provider if patient has more questions or doesn't understand information
provided
20. RESTRAINTS - *Physical*
TYPES - vest
- belt
- mitten
*Chemical*
, ATI CMS EXAM REVIEW - MENTAL HEALTH
Study online at https://quizlet.com/_68mi41
- sedative Rx
- antipsychotic Rx
21. RESTRAINTS - AL- provide verbal interventions
TERNATIVES
diversions
calm/quiet environment
22. RESTRAINTS - *MUST BE IN WRITING*
PRESCRIPTIONS
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)
23. RESTRAINTS - *Adults*
TIME LIMITS 4 hours
*Ages 9 - 17*
2 hours
*Ages 8 and Under*
1 hour
24. RESTRAINTS - complete every 15-30 minutes
DOCUMENTA-
TION *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)
