A nurse is assigned to care for a 28-year-old patient with seizures and neuropsychiatric symptoms secondary to cocaine abuse. The patient is combative and prone to hurting himself despite a 24-hour bedside sitter, so the provider writes for physical restraints. Which options are included in this order? Select all that apply.

Mittens, Side rails up x 4 , Placing a patient in a room alone. A physical restraint is any non-chemical intervention that prevents the patient from moving or using part or all of his or her body. Mittens prevent the patient from using his or her hands. Having all four bedside rails up while the patient is in bed prevents the patient from leaving the bed and is therefore considered a physical restraint. Seclusion, or placing a patient in a room alone to calm down, is considered a physical restraint since they are unable to leave. Low dose lorazepam is an anti-anxiety medication. At high doses, lorazepam can be considered a chemical restraint. Assigning an unlicensed assistive personnel to sit next to the patient’s bed and reorient them is not a restraint.

A nurse is assigned to care for a 28-year-old patient with seizur...

Category: Safety and Infection Control
Difficulty: 5

Topics: Communication & Documentation Crisis Management Cognition Health Care Ethics, Law, and Policy Lifestyle Choices and High Risk Behavior Mental Health Disorders Nursing Interventions

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Which situations prompt the use of four-point restraints? Select all that apply.

Question Type: Multiple Choice - Select All
Difficulty: 5

The nurse is caring for the patient with a stage 2 pressure injury on the right heel. The wound is pink with minimal serous drainage and attached borders. Periwound skin is clean, dry, and intact. Which intervention is appropriate for this patient?

Question Type: Multiple Choice - Select One
Difficulty: 4

A nurse is assigned to care for a 45-year-old male who is admitted for alcohol withdrawal. On the second day of admission, the patient becomes disoriented and combative, and the provider places him in bilateral wrist restraints. Which physical exam finding is most important for this patient?

Question Type: Multiple Choice - Select One
Difficulty: 6

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