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The nurse is reviewing documentation after restraints were used. What item from the documentation should be removed?

A.

Interventions that were used prior to the use of restraint

B.

Least-restrictive measures used prior to the use of restraint

C.

The patient’s behavior that led to the use of restraint

D.

The names of people the patient harmed during the violent episode

Answer and Explanation

The Correct Answer is D

A: Documenting interventions used prior to the use of restraint is necessary to show that all other options were exhausted before resorting to restraints.

B: Documenting least-restrictive measures used prior to the use of restraint is important to demonstrate that the least restrictive options were attempted first.

C: Documenting the patient’s behavior that led to the use of restraint is crucial for justifying the use of restraints and for future care planning.

D: The names of people the patient harmed during the violent episode should be removed to protect their privacy and confidentiality.


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Related Questions

Correct Answer is B

Explanation

A: Encouraging clients to participate in various activities is a positive approach that helps engage them in the program and develop new skills.

B: Allowing the client to skip mandatory programming as a reward for good behavior is inappropriate because it undermines the structure and consistency of the program. Mandatory programming is essential for therapeutic progress and should not be used as a reward or punishment.

C: Ignoring attention-seeking behavior, such as screaming, can be an appropriate strategy to avoid reinforcing negative behaviors, provided it is done within the context of a behavior management plan.

D: Removing a client from group after they become disruptive, per unit policy, is an appropriate action to maintain the therapeutic environment and ensure the safety and well-being of all clients.

Correct Answer is C

Explanation

A: Naloxone is used to reverse opioid overdoses, not LSD intoxication.

B: Seclusion and restraint should be used only if the patient poses an immediate threat to themselves or others and other de-escalation techniques have failed.

C: Offering reassurance and emotional support is the primary approach for managing a patient under the influence of LSD. Providing a calm and supportive environment helps reduce anxiety and agitation.

D: Respiratory complications are not typically associated with LSD use. Intubation is not a standard response for LSD intoxication unless there are other complicating factors.

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