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ATI Mental Health assessment
ATI Mental Health assessment ( 50 Questions)
A nurse is caring for a client who is aggressive toward other clients and has been placed in wrist restraints. After obtaining a prescription for restraints from the provider, which of the following actions should the nurse take?
Document the client's behavior once every hour: Documenting the client's behavior at regular intervals is essential to monitor their condition while in restraints. However, hourly documentation might not be sufficient, especially if there are significant changes in the client's status or behavior.
Keep the client in restraints until the prescription expires: Restraints should be used for the shortest duration necessary to ensure the safety of the client and others. Keeping the client restrained until the prescription expires without reevaluation may not align with best practices for restraint use.
Conduct a debriefing regarding the client with the unit staff: Debriefing with the unit staff can provide an opportunity to discuss the client's behavior, response to interventions, and any concerns. This can help ensure continuity of care and identify any areas for improvement in managing similar situations in the future.
Request an evaluation of the client within 12 hr of application of restraints: Regular evaluations of the client's condition and the need for continued restraint use are essential to prevent unnecessary restraint use and ensure the client's well-being. Requesting an evaluation within 12 hours of applying restraints aligns with best practices for restraint use and ensures timely reassessment of the client's status.
A. Document the client's behavior once every hour: Documenting the client's behavior at regular intervals is essential to monitor their condition while in restraints. However, hourly documentation might not be sufficient, especially if there are significant changes in the client's status or behavior.
B. Keep the client in restraints until the prescription expires: Restraints should be used for the shortest duration necessary to ensure the safety of the client and others. Keeping the client restrained until the prescription expires without reevaluation may not align with best practices for restraint use.
C. Conduct a debriefing regarding the client with the unit staff: Debriefing with the unit staff can provide an opportunity to discuss the client's behavior, response to interventions, and any concerns. This can help ensure continuity of care and identify any areas for improvement in managing similar situations in the future.
D. Request an evaluation of the client within 12 hr of application of restraints: Regular evaluations of the client's condition and the need for continued restraint use are essential to prevent unnecessary restraint use and ensure the client's well-being. Requesting an evaluation within 12 hours of applying restraints aligns with best practices for restraint use and ensures timely reassessment of the client's status.