Comprehensive exams for Mental Health Q 180
Nurse Jannah is monitoring a male client who has been placed in restraints because of violent behavior. Nurse determines that it will be safe to remove the restraints when:
A. The client verbalizes the reasons for the violent behavior.
B. The client apologizes and tells the nurse that it will never happen again.
C. No acts of aggression have been observed within 1 hour after the release of two of the extremity restraints.
D. The administered medication has taken effect.
Correct Answer: C. No acts of aggression have been observed within 1 hour after the release of two of the extremity restraints.
The best indicator that the behavior is controlled if the client exhibits no signs of aggression after partial release of restraints. When the patient is no longer a danger to themselves or others, the restraints should be removed immediately. The Occupational Safety and Health Administration (OSHA) stated that 75% of annual assaults in the workplace occur in the healthcare and social service fields. As reported in the National Crime Victimization Survey, healthcare workers face a 20% higher chance of being victimized in the workplace when compared to other workers.
Option A: The impetus to administer restraint and seclusion protocol is to obviate potential violence and potentiate harm reduction. Hazards to be avoided include both harm to the patient and the caretaker. This danger encompasses both nonviolent and violent risks. Healthcare providers are encouraged to always remain vigilant. Violence history remains the best predictor for future violence. The classic escalation of patient violence progresses from anger, resistance, and finally to confrontation. Signs of impending violent behavior include provocative behavior, posturing, pacing, angry demeanor, and aggressive acts.
Option B: Once an agitated patient has been identified, staff must give the patient the opportunity to calm down before physical intervention. Often, agitated but cooperative patients will be amenable to verbal de-escalation. Guidelines recommend an honest and straightforward approach with the implementation of friendly gestures proves most beneficial in the setting of an agitated patient. Following fruitless de-escalation techniques, emergency seclusion and restraint can be indicated.
Option D: This does not ensure that the client has controlled the behavior. Document appropriate clinical indications and have a standardized checklist prepared for staff to monitor and supply patient needs effectively. Numerous deaths and adverse patient outcomes have been reported due to inappropriate restraint placement and negligent monitoring. After restraint placement, patients should be reevaluated every hour and moved at regular intervals to prevent sequelae such as pressure ulcers, rhabdomyolysis, and paresthesias.