An individual was brought to the emergency room with impaired ...

[Alygatorr01285]

An individual was brought to the emergency room with impaired cognitive function. The patient's aggressive behavior and attempts to get out of bed present a safety issue. The nurse should first:
 
  a. apply four-point restraints.
  b. use a calm tone to orient the patient.
  c. assign staff to stay in the room with the patient.
  d. call for security guards to assist with controlling the patient.

Question 2

A nurse documents that a patient is appropriately emotionally responsive, in control, and expresses a unified philosophy of life. This implies that the patient has met the mental health criterion of:
 
  a. autonomy.
  b. integration.
  c. reality perception.
  d. environmental mastery.

[juicepod]

Answer to Question 1

B
Reality orientation is generally helpful to patients with cognitive impairment. A patient who is misinterpreting reality should be reoriented by a nurse who uses a calm manner and soothing voice. Reorientation is the least restrictive way of addressing the behaviors. Restraints or holding the patient down would increase agitation; assigning staff to stay with the patient continuously is not appropriate as an initial intervention.

Answer to Question 2

B
Integration refers to a balance between what is expressed and what is repressed and a regulation of moods and emotions, and it includes the characteristics mentioned in the question.