The nurse educator is planning various seminars for the staff ...

[Marty]

The nurse educator is planning various seminars for the staff nurses regarding care of the patient in physical restraints. Which essential nursing interventions will the educator include in the staff seminar? Select all that apply.
 
  1. Turn patient every 4 hours.
  2. Toilet the patient as needed.
  3. Assign one-to-one observation.
  4. Assess skin integrity every hour.
  5. Assess circulation, sensation, and movement every 6 hours.

Question 2

The nurse educator is providing education to the staff nurses regarding the use of seclusion in the psychiatric setting. The educator asks the nurses to describe patients who would best benefit from seclusion.
 
  Which statements by the nurses would indicate that teaching has been effective? Select all that apply.
  1. The patient who throws a book on the ground in frustration.
  2. The patient who is loud and disrupting the milieu of the unit.
  3. The patient who attempts to cut herself with an object found on the unit.
  4. The patient who hits another patient in the face during a therapy session.
  5. The patient who is confused and disoriented with altered thought processes.

[heinisk01]

Answer to Question 1

Answer: 2, 3, 4
Explanation: Appropriate nursing interventions for the patient in physical restraints include toileting the patient as needed, assigning a one-to-one observation, and assessing the patient's skin integrity every hour. The nurse should turn the patient and assess circulation, sensation, and movement every 2 hours, not every 4 or 6 hours.

Answer to Question 2

Answer: 3, 4
Explanation: Seclusion is an intervention that may be used in the inpatient psychiatric setting to protect a patient who is a danger to self or to protect others from injury when imminent risk is present. The patient who attempts to cut herself and the patient who hits another patient are patients who would benefit from seclusion. The patient who throws a book on the ground and the patient who is loud and disruptive are not displaying a physical threat to self or others. Rather, these patients are displaying escalating anxiety and would benefit from therapeutic communication interventions, not seclusion. The patient with altered thought processes would benefit from reorientation, not seclusion.

[Marty]

Excellent

[gcook]

TYSM