A patient becomes agitated and physically aggressive on the unit, requiring the use of restraints. Which of the following actions by the nurse is appropriate when applying and managing restraints?

Apply restraints and leave the patient unattended for 2 hours

Restrain the patient to the bed using all four limbs tightly to limit any movement

Ensure a provider’s face-to-face evaluation occurs within 1 hour of restraint application

Document the restraint use once at the end of the shift

Answer and Explanation

The Correct Answer is C

Choice A reason: Leaving a restrained patient unattended for 2 hours violates safety standards, as restraints pose risks like injury or respiratory compromise. Regular monitoring is required to assess circulation, skin integrity, and psychological distress, ensuring patient safety, making this choice incorrect.

Choice B reason: Restraining all four limbs tightly risks injury, such as nerve damage or impaired circulation, and violates least-restrictive restraint principles. Restraints should allow minimal movement and be applied only as necessary, with regular reassessment, making this choice incorrect.

Choice C reason: A provider’s face-to-face evaluation within 1 hour is required by regulations to ensure restraints are justified and safe. This assesses the patient’s condition, mental status, and need for continued restraint, minimizing harm and ensuring compliance, making this the correct choice.

Choice D reason: Documenting restraint use only at shift’s end is inadequate, as regulations require ongoing documentation of restraint rationale, patient condition, and monitoring. Delayed documentation risks missing critical changes, compromising care and legal compliance, making this choice incorrect.

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Correct Answer is D

Explanation

Choice A reason: The irresistible impulse test focuses on a defendant’s inability to control their actions due to mental illness, even if they understand the act’s wrongfulness. The scenario emphasizes the patient’s lack of understanding of wrongfulness, not impulse control, making this choice incorrect for the legal standard described.

Choice B reason: The substantial capacity test, part of the Model Penal Code, assesses whether a defendant lacks the capacity to appreciate the criminality of their conduct or conform to the law. The scenario specifically highlights not understanding wrongfulness, aligning more directly with M’Naghten, making this less precise.

Choice C reason: The Durham Rule states that a defendant is not criminally responsible if their act was a product of mental disease. It is broader and less specific than M’Naghten, which focuses on understanding wrongfulness, making it less applicable to the scenario described.

Choice D reason: The M’Naghten Rule holds that a defendant is not guilty by reason of insanity if, due to mental illness, they did not understand the nature or wrongfulness of their actions. This directly matches the scenario’s emphasis on the patient’s inability to understand wrongfulness, making it the correct choice.

A. Durham Rule B. M’Naghten Rule C. Tarasoff Rule D. Irresistible impulse

Correct Answer is D

Explanation

Choice A reason: The Durham Rule holds that a defendant is not criminally responsible if their act was a product of mental disease. It is broad and does not specifically address the inability to control behavior despite knowing wrongfulness, making it less applicable than irresistible impulse.

Choice B reason: The M’Naghten Rule focuses on a defendant’s inability to understand the nature or wrongfulness of their actions due to mental illness. The scenario emphasizes inability to control behavior, not lack of understanding, making this choice incorrect.

Choice C reason: The Tarasoff Rule requires clinicians to warn potential victims of a patient’s threat, unrelated to insanity defenses. It addresses duty to protect, not the legal standard for criminal responsibility, making this choice irrelevant to the scenario.

Choice D reason: The irresistible impulse standard applies when a defendant understands their actions were wrong but cannot control their behavior due to mental illness. This matches the scenario, where the patient’s inability to control actions led to the insanity ruling, making this the correct choice.

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A patient becomes agitated and physically aggressive on the unit, requiring the use of restraints. Which of the following actions by the nurse is appropriate when applying and managing restraints?

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

Correct Answer is D

Explanation

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