NSG 262 Exam 1 With Complete
Solution
The goal of health care facilities (regarding restraints) - ANSWERa restraint
free environment
Are orders always needed for restraints? - ANSWERyes
Do you need consent for all restraints? - ANSWERno
Chemical restraints are illegal if used for.... - ANSWERconvenience or
discipline
Restraints - ANSWERmay be necessary to prevent injury to self/others or to
protect medically necessary equipment
> CMS, The Joint Commission, Medicare, and Medicaid all have regulations
and requirements
Medicare - ANSWERhealth insurance for people 65 and older
> you want to "care" for people who are old
Medicaid - ANSWERa federal and state assistance program that pays for
health care services for people who cannot afford them
> you want to "aide" people with low income
Restraint Regulations - ANSWER> try to prevent the use of a restraint
> use of the least restrictive restraint that fulfills the need
> monitor and care for the patient while having the restraint
,Restraint Preventative Measures - ANSWER> frequent monitoring
> reorienting and reminding patients about asking for assistance
> use of sitters
> place patient close to nursing station
> diversion
Protective Devices - ANSWER> safety devices that are NOT restraints, even
though they limit movement
> used to assist with procedures or treatment
> patient has the right to refuse
Ex: IV board, limb stabilizing devices, helmets, splints, surgical dressings
Types of Restraints - ANSWER1.) Behavioral
2.) Medical (Physical or Chemical)
Behavioral Restraint - ANSWERuse of restraint or seclusion when warranted
by patient behavior that threatens the physical safety of the patient, staff, or
others
> history of previous violence does NOT support using a restraint, behavior
must be current
> restraints should NEVER be used for staff convenience
Ex: arm and leg restraints, chemical, leather restraints, shackles
Chemical Restraint - ANSWERany drug used for discipline or convenience and
not required to treat medical symptoms
, Ex: sedating medication for seductive behavior
Physical Restraints - ANSWERany method of physical or mechanical device,
material, or equipment used on a patient to restrict freedom of movement or
normal access to one's body
Ex: soft wrist restraints, mittens, bedsheet to keep patient in bed or chair, full
side rails
Why are vest restraints rarely used now? - ANSWERrisk of strangulation
A physician's restraint order must be started within.... - ANSWER1 to 4 hours
After applying restrain the nurse will check on the restraint for the first hour
every... - ANSWER15 minutes
A restrain must be released every... - ANSWER2 hours
For non-behavioral reasons, restraint care must be documented every... -
ANSWER2 hours
For behavioral reasons, restraint care must be documented every... -
ANSWER4 hours
a new restraint order is needed every.... - ANSWER24 hours
Restraint Education - ANSWERstaff must be trained on the use of the
restraint seclusion, assessing their competence during...
1.) orientation
2.) before participating in the use of a particular restraint
3.) periodically
What is included on a restraint order? - ANSWER> type of restraint
Solution
The goal of health care facilities (regarding restraints) - ANSWERa restraint
free environment
Are orders always needed for restraints? - ANSWERyes
Do you need consent for all restraints? - ANSWERno
Chemical restraints are illegal if used for.... - ANSWERconvenience or
discipline
Restraints - ANSWERmay be necessary to prevent injury to self/others or to
protect medically necessary equipment
> CMS, The Joint Commission, Medicare, and Medicaid all have regulations
and requirements
Medicare - ANSWERhealth insurance for people 65 and older
> you want to "care" for people who are old
Medicaid - ANSWERa federal and state assistance program that pays for
health care services for people who cannot afford them
> you want to "aide" people with low income
Restraint Regulations - ANSWER> try to prevent the use of a restraint
> use of the least restrictive restraint that fulfills the need
> monitor and care for the patient while having the restraint
,Restraint Preventative Measures - ANSWER> frequent monitoring
> reorienting and reminding patients about asking for assistance
> use of sitters
> place patient close to nursing station
> diversion
Protective Devices - ANSWER> safety devices that are NOT restraints, even
though they limit movement
> used to assist with procedures or treatment
> patient has the right to refuse
Ex: IV board, limb stabilizing devices, helmets, splints, surgical dressings
Types of Restraints - ANSWER1.) Behavioral
2.) Medical (Physical or Chemical)
Behavioral Restraint - ANSWERuse of restraint or seclusion when warranted
by patient behavior that threatens the physical safety of the patient, staff, or
others
> history of previous violence does NOT support using a restraint, behavior
must be current
> restraints should NEVER be used for staff convenience
Ex: arm and leg restraints, chemical, leather restraints, shackles
Chemical Restraint - ANSWERany drug used for discipline or convenience and
not required to treat medical symptoms
, Ex: sedating medication for seductive behavior
Physical Restraints - ANSWERany method of physical or mechanical device,
material, or equipment used on a patient to restrict freedom of movement or
normal access to one's body
Ex: soft wrist restraints, mittens, bedsheet to keep patient in bed or chair, full
side rails
Why are vest restraints rarely used now? - ANSWERrisk of strangulation
A physician's restraint order must be started within.... - ANSWER1 to 4 hours
After applying restrain the nurse will check on the restraint for the first hour
every... - ANSWER15 minutes
A restrain must be released every... - ANSWER2 hours
For non-behavioral reasons, restraint care must be documented every... -
ANSWER2 hours
For behavioral reasons, restraint care must be documented every... -
ANSWER4 hours
a new restraint order is needed every.... - ANSWER24 hours
Restraint Education - ANSWERstaff must be trained on the use of the
restraint seclusion, assessing their competence during...
1.) orientation
2.) before participating in the use of a particular restraint
3.) periodically
What is included on a restraint order? - ANSWER> type of restraint
