A patient is ready to be released from leather four-point restraints (restraints on both wrists and both ankles). Place the following actions involved in releasing a patient from restraints in their correct order
A. Maintain the patient in seclusion and reassess.
B. Complete the removal of the restraints.
C. Continue to observe the patient closely.
D. Reassess the patient for safety.
E. Release one ankle from restraint.
F. Remove the patient from seclusion.
1 . E
2 . D
3 . B
4 . A
5 . F
6 . C
The patient should be removed from restraints and reintegrated to the unit in a step-wise, progressive fashion. Restraints are removed one at a time, usually with one ankle removed first. After reassessment to assure that the patient is safe to continue the release, the restraint on the wrist opposite the free ankle is removed, and after reassessment, the remaining two restraints are removed. The patient should then remain at least briefly in seclusion for further observation and assessment, then be returned to the unit, at which time close observation should continue in case the patient's condition deteriorates again amidst the greater stimulation and reduced external controls that characterize the unit proper.
You might also like to view...
During an assessment, the nurse notes that the patient's apical impulse is laterally displaced and is palpable over a wide area. This finding indicates:
a. Systemic hypertension. b. Pulmonic hypertension. c. Pressure overload, as in aortic stenosis. d. Volume overload, as in heart failure.
A team of nurses are reviewing the similarities and differences between the different classifications of shock. Which subclassifications of circulatory shock should the nurses identify? Select all that apply
A) Anaphylactic B) Hypovolemic C) Cardiogenic D) Septic E) Neurogenic
A male patient comes to the emergency department with symptoms of renal colic. The nurse realizes that this patient likely has a calculus that is obstructing which body structure?
1. ureter 2. bladder 3. renal pelvis 4. urethra
Your client's family caregiver is experiencing Caregiver role strain. Which of the following are defining characteristics of this diagnosis?
1. feelings of dread, fright, and apprehension 2. apprehension about the client's future health, the caregiver's ability to provide care, and possible need to institutionalize the client 3. verbalization of uncertainty about choices and delayed decision-making 4. behaviors of avoidance; narrowing of focus on danger; and deficits in attention, performance, and control