with Accurate Solved Solutions
Graded A+ 2025-2026 Edition.
Because clients have a right to the least restrictive environment of care, restraints should be
used as a - Answer last option
used only after a careful assessment has been completed and the nurse determines that the
client is a danger to self or others other methods have been unsuccessful.
False imprisonment is the - Answer unlawful restraint of an individual's personal freedom or
the unlawful restraint or restriction of an individual.
A physical restraint - Answer mechanical or physical device, which prevents free movement by
the client. Examples of physical restraints are wrist or ankle restraints, a jacket or vest, and side
rails
chemical restraint. - Answer A medication that is administered to a client to control behavior
One of the biggest misconceptions is that physical restraints prevent - Answer falls
fall-related injuries - Answer increased with the use of restraints. Skin impairment,
incontinence, serious injuries (like broken bones), and even death have been associated with
restraint use.
ANA Recommendations - Answer -Promote policies for restraint-free cultures
-Implement alternatives and less restrictive measures
alternatives and less restrictive measures to use of restraints - Answer •verbal de-escalation
techniques and in-person or electronic remote 1:1 continuous client observation.
supplies health insurance and reimbursement - Answer the Center for Medicaid & Medicare
Services (CMS)
Things that should be included in this documentation Are: - Answer •client behavior that
, -ongoing assessment of the continued need for restraints
-The client's response
Medication reconciliation - Answer a formal evaluative process in which the client's current
medications are compared with their medications at time of admission, transfer, or discharge to
identify and resolve discrepancies.
The information that clinicians use to reconcile medications include - Answer drug name,
dose, frequency, route, and purpose.
The process of medication reconciliation is as follows: - Answer •At time of admission to the
hospital obtain, verify, and document the client's current prescription and meds—including
vitamins, supplements, eye drops, creams, ointments, and herbals.
•The client's pre-admission/home medication list should be considered when ordering
medicines during a hospital encounter. The client's pre-admission/home medication list should
be compared to ordered meds and treatment plans to identify unintended discrepancies.
Once the home medication list has been verified, discuss unintended discrepancies with -
Answer the provider for resolution.
Provide the client with an updated - Answer med list and communicate the importance of
managing medication information upon discharged from the hospital or at the end of an
outpatient encounter
Use untied, cloth-padded protective mitts on the patient's hands to prevent the patient from
removing tubes or drains. is an example of - Answer an alternative restraint
In the event of an immediate threat of harm to self or others - Answer the nurse can apply a
physical restraint without an order from the primary care provider (PCP), but the order must be
sought and the patient must be seen within an hour of application of the restraint.
Never tie a restraint in a - Answer knot
Restraints should never be tied to - Answer bed rails