Examkin

Soru

Zorluk: OrtaSafe Use of Restraints and Safety Devices

An adolescent client admitted to an acute behavioral health facility begins throwing furniture and physically threatening peers. After verbal de-escalation and pharmacological interventions fail to calm the client, four-point mechanical restraints are applied to prevent immediate severe injury. Which action must the registered nurse implement next?

  1. Initiate continuous, in-person observation of the client for the duration of the restraint use.Cevap
  2. B
    Secure the restraint straps to the adjustable side rails of the bed using square knots.
  3. C
    Contact the healthcare provider to obtain a PRN (as-needed) prescription for mechanical restraints.
  4. D
    Delegate the ongoing assessment of peripheral circulation and respiratory status to the unlicensed assistive personnel.

Cevap

Initiate continuous, in-person observation of the client for the duration of the restraint use.
When mechanical restraints are applied for violent or self-destructive behavior, strict safety standards require continuous, in-person observation of the client. This one-to-one monitoring is critical to immediately detect respiratory compromise, impaired circulation, or changes in psychological status, ensuring the restraints can be removed at the earliest possible safe moment.

Adım Adım Çözüm

1
Identify the type of restraint indication described in the clinical scenario.
The client is exhibiting violent, self-destructive behavior that poses an immediate physical threat.
Different restraint indications (medical-surgical vs. violent/behavioral) have distinct regulatory requirements for monitoring and order renewal.
2
Determine the safety and monitoring requirements specific to violent behavioral restraints.
Standards require continuous, face-to-face observation by a trained staff member.
Continuous monitoring ensures the client's airway and circulation are not compromised and allows for rapid removal once the client is no longer an imminent threat.
3
Evaluate the remaining options against legal and safety standards for restraints and delegation.
Using square knots on side-rails, obtaining PRN orders, and delegating clinical assessments to unlicensed assistive personnel (UAP) are all severe safety violations.
Eliminating unsafe practices isolates the correct evidence-based nursing action.

Anahtar Kavram

Management of Violent and Behavioral Restraints
Tahmini Süre:1m 30s
Bu soruyu puanla

Konular

Safe Use of Restraints and Safety Devices

Bu konudan daha fazla soru