An aggressive client has been placed in restraints after all ...

[storky111]

An aggressive client has been placed in restraints after all other interventions have failed. Which protocol would apply in this situation?
 
  1. An in-person evaluation by a physician or other licensed independent practitioner must be conducted within 1 hour of the initiation of the restraints.
  2. An in-person evaluation by a physician or other licensed independent practitioner must be conducted within 2 hours of the initiation of the restraints.
  3. An in-person evaluation by a physician or other licensed independent practitioner must be conducted within 3 hours of the initiation of the restraints.
  4. An in-person evaluation by a physician or other licensed independent practitioner must be conducted within 4 hours of the initiation of the restraints.

Question 2

Which nursing diagnosis should be prioritized when providing nursing care to a client diagnosed with avoidant personality disorder?
 
  1. Risk for violence: directed toward others R/T paranoid thinking
  2. Risk for suicide R/T altered thought
  3. Altered sensory perception R/T increased levels of anxiety
  4. Social isolation R/T inability to relate to others

[rosiehomeworddo]

Answer to Question 1

1
Rationale: The Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations JCAHO) requires that an in-person evaluation by physician or other licensed independent practitioner be conducted within 1 hour of the initiation of restraint or seclusion.

Answer to Question 2

4
Rationale: The priority nursing diagnosis for a client diagnosed with avoidant personality disorder should be social isolation R/T inability to relate to others. These clients avoid close or romantic relationships, interpersonal attachments, and intimate sexual relationships.