The nurse is caring for a patient in restraints. Which essential ...

[ap345]

The nurse is caring for a patient in restraints. Which essential information will the nurse document in the patient's medical record to provide safe care? (Select all that apply.)
 
  a. One family member has gone to lunch.
  b. Patient is placed in bilateral wrist restraints at 0815.
  c. Bilateral radial pulses present, 2+, hands warm to touch
  d. Straps with quick-release buckle attached to bed side rails
  e. Attempts to distract the patient with television are unsuccessful.
  f. Released from restraints, active range-of-motion exercises completed

Question 2

The nurse is assessing a patient who reports a previous fall and is using the SPLATT acronym. Which questions will the nurse ask the patient? (Select all that apply.)
 
  a. Where did you fall?
  b. What time did the fall occur?
  c. What were you doing when you fell?
  d. What types of injuries occurred after the fall?
  e. Did you obtain an electronic safety alert device after the fall?
  f. What are your medical problems that may have caused the fall?

[carojassy25]

Answer to Question 1

ANS: B, C, E, F
Proper documentation, including the behaviors that necessitated the application of restraints, the procedure used in restraining, the condition of the body part restrained (e.g., circulation to hand), and the evaluation of the patient response, is essential. Record nursing interventions, including restraint alternatives tried, in nurses' notes. Record purpose for restraint, type and location of restraint used, time applied and discontinued, times restraint was released, and routine observations (e.g., skin color, pulses, sensation, vital signs, and behavior) in nurses' notes and flow sheets. Straps are not attached to side rails. Comments about the activities of one family member are not necessarily required in nursing documentation of restraints.

Answer to Question 2

ANS: A, B, C, D
Assess previous falls; using the acronym SPLATT:
Symptoms at time of fall
Previous fall
Location of fall
Activity at time of fall
Time of fall
Trauma after fall
Medical diagnoses and an alert device are not components of SPLATT.

[ap345]

Excellent

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