Personality and Mood Disorders Q 71
The client jumps up and throws a chair out of the window. He was restrained after his behavior can no longer be controlled by the staff. Which of these documentations indicates the safeguarding of the patient’s rights?
A. There was a doctor’s order for restraints/seclusion.
B. The patient’s rights were explained to him.
C. The staff observed confidentiality.
D. The staff carried out less restrictive measures but were unsuccessful.
Correct Answer: D. The staff carried out less restrictive measures but were unsuccessful.
This documentation indicates that the client has been placed in restraints after the least restrictive measures failed in containing the client’s violent behavior. Chart, in nurse’s notes, behaviors; interventions; what seemed to escalate agitation; what helped to calm agitation; when as-needed (PRN) medications were given and their effect; and what proved most helpful.
Option A: If nursing interventions (quiet environment and firm limit setting) and chemical restraints (tranquilizers–e.g., haloperidol [Haldol]) have not helped dampen escalating manic behaviors, then seclusion might be warranted.
Option B: Use a calm and firm approach. Provides structure and control for a client who is out of control. Use short, simple, and brief explanations or statements. A short attention span limits understanding to small pieces of information.
Option C: Frequently assess client’s behavior for signs of increased agitation and hyperactivity. Staff will begin to recognize potential signals for escalating manic behaviors and have a guideline for what might work best for the individual client.