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What are the guidelines that nurses should follow when considering whether or not a client requires restraints? When considering whether or not a client requires restraints, the nurse should determine if the client needs restraints, like if they are a danger to him or herself, or to others. They should determine if all alternative interventions to the use of restraints have been taken, like using bed or chair alarms, distraction, frequent monitoring, utilizing a sitter, etc. A client on the mental health unit is being discharged to a community base program referred to as Assertive Community Treatment (ACT). What should the nurse explain to the client about this program? ACT is an effective treatment program that helps people with serious mental illness that do not usually respond to other treatments. People receive individualized care from various multidisciplinary members in the outpatient setting that helps them function in the community and reduces their chance of being readmitted to the hospital. People are accompanied to different appointments and receive help with things in their life such as finding a job/home, managing money, and obtaining transportation. A client has become very aggressive. List de-escalation techniques the nurse will want to implement to address the behavior of the client. 1. Communicate with the client in a clear and calm way. 2. Identify the wants/needs of the client. 3. When approaching the client, use non-threatening body language. 4. Display respect, empathy and compassion towards the client. 5. Allow the patient to vent in order for them to feel validated. A client has been admitted to an inpatient mental health facility and close observation has been ordered. List the rights of the client when admitted with this level of management. 1. The client has the right to informed of their rights in the inpatient mental health facility. 2. The client has the right to refuse treatment, or services. 3. The client can refuse observation techniques, such as the use of tape recorders 4. The client has the right to be informed about diagnosis/condition. 5. The client has the right to confidentiality. Which of the following client would be the priority to assess first? A client diagnosed with schizophrenia that is exhibiting negative symptoms, a client with a substance-induced psychotic disorder related to substance intoxication, a client who is suffering from delusion of grandeur, a client suffering from olfactory hallucinations. The priority client to assess is the client diagnosed with a substance-induced psychotic disorder related to substance intoxication. The nurse must address the psychosis and intoxication. The client states that she is going through a divorce and her anxiety is extremely high. The nurse needs to assess the client’s ability to adapt and cope with this situation. What would this include? The nurse should assess how the client is physically reacting to anxiety by the use of observation and asking the client questions in a therapeutic manner. The nurse can assess the client’s health What are the guidelines that the nurse should follow when considering whether or not a client requires restraints?In emergency situations, nurses may apply restraints without consent when a serious threat of harm to the patient or others exists and only after all alternative interventions were unsuccessful. Restraint use should be continually assessed by the health care team and reduced or discontinued as soon as possible.
Which of the following should the nurse include as a criterion for applying restraints?Which of the following should the nurse include as a criterion for applying restraints? The nurse has already considered alternatives to restraints.
Which intervention should a nurse implement before applying restraints?Before applying restraints, the nurse must exhaust alternative measures to restraints such as a bed alarm, distraction, and a sitter. If the nurse determines that a restraint is necessary, its use is discussed with the client and family and a prescription is obtained from the health care provider.
How should the nurse determine that the restraints are not too constrictive?How should the nurse determine that the restraints are not too constrictive? Place two fingers under the restraint to determine snugness. The nurse is assisting with planning care for a client with an internal radiation implant.
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What are the guidelines that nurses should follow when considering restraints quizlet?
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