Question 1

Which of the following is the most appropriate first step when considering the use of restraints for a confused patient who is pulling at their IV line?

Accepted Answer

Assess the patient to discover the cause of the behavior.

Question 2

A patient is at risk of falling from a chair. Which type of restraint is most appropriate according to the indications provided?

Accepted Answer

Lap or belt restraint

Question 3

Which of the following is NOT a recommended alternative intervention before resorting to restraints?

Accepted Answer

Apply 4-point soft restraints

Question 4

Which of the following is a potential complication of long-term restraint use?

Accepted Answer

Pressure ulcers

Question 5

A physician's order for restraints must include all of the following EXCEPT:

Accepted Answer

Patient's insurance information

Question 6

During a seizure, which of the following actions is appropriate?

Accepted Answer

Loosen tight clothing and clear the surrounding area.

Question 7

Which of the following is a chemical restraint?

Accepted Answer

Sedatives

Question 8

According to the least-restraint approach, what must be ensured before applying restraints?

Accepted Answer

All alternative interventions have been attempted.

Question 9

Which of the following is a nursing responsibility when a patient is under restraint?

Accepted Answer

Monitor for injury, circulation, and readiness for discontinuation.

Question 10

Which of the following is a sign that may occur in the post-ictal phase of a seizure?

Accepted Answer

Confusion

Question 11

A patient is at risk of pulling out tubes and hitting others. Which restraint is most appropriate?

Accepted Answer

Wrist restraints

Question 12

Which of the following is a hazard associated with the use of restraints?

Accepted Answer

Urinary retention

Question 13

Which of the following is a category in the Hendrich II Fall Risk Model?

Accepted Answer

Depression

Question 14

Which formula best represents the calculation of total Morse Fall Scale score?

Accepted Answer

$Total = \sum_{i=1}^{6} Risk\ Factor_i$

Question 15

Which of the following is NOT one of the '4 Ps' of purposeful rounding for fall prevention?

Accepted Answer

Pressure ulcers

Question 16

A patient with epilepsy is found confused and lethargic after a seizure. Which phase is this most likely?

Accepted Answer

Post-ictal

Question 17

Which of the following is an example of an environmental restraint?

Accepted Answer

Secure unit

Question 18

Which of the following is a correct nursing procedure when applying restraints?

Accepted Answer

Explain the procedure to the patient and family.

Question 19

Which of the following is a complication that may occur during a seizure?

Accepted Answer

Aspiration pneumonia

Question 20

Which of the following is a correct statement regarding the use of restraints?

Accepted Answer

Restraints must be used only after exhausting all alternative interventions.

Client Safety: Restraints, Seizure Precautions, and Fall Prevention – Structured Study Notes

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