2021 Behavioral Health RN, MHW, CNA Restraint Competency

1.

Use the following Scenario to answer the next four questions: A 13 year old boy has displayed behavioral outbursts by throwing chairs and his entire meal tray at staff. Prior to this outburst staff noted increased tone/volume of speech and abrupt responses to questions as the first signs of agitation as he waited for dinner to arrive. Staff announced that dinner was a little late and encouraged him to utilize his coping skills of progressive muscle relaxation and music therapy while waiting. As dinner arrived and patient was handed his meal tray he yelled "This is not even my order." A CODE was called and other patients were asked to retreat to their rooms temporarily. When you have read this scenario: Answer yes in the box that you've read this scenario

2.

A "Restraint" is defined as (select the best choice):

A.

Any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely
B.

Any manual method, physical or mechanical device, material/equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head involuntarily
C.

A device used to enforce discipline
D.

None of the above are correct

Correct Answer
A. Any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely

Explanation
The correct answer is "Any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely." This definition accurately describes a restraint as a method or device used to restrict a patient's movement, ensuring they are unable to freely move their limbs or body. This definition does not include any mention of involuntary movement or disciplinary enforcement, which are not accurate descriptions of a restraint.

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3.

Only non-violent patients, legal guardians and immediate family members will be notified of the patient's rights regarding restraints/seclusion

A.

True
B.

False

Correct Answer
B. False

Explanation
The correct answer is False because not only non-violent patients, legal guardians, and immediate family members will be notified of the patient's rights regarding restraints/seclusion. Other individuals such as healthcare professionals, social workers, and legal authorities may also be informed about these rights to ensure the patient's safety and well-being.

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4.

Which of the following are considered "Non-violent" forms of restraints? Select All that apply

A.

2 point soft restraint
B.

Use of 2 side rails
C.

Mittens
D.

Use of 4 side rails to restrict freedom

Correct Answer(s)
A. 2 point soft restraint
C. Mittens
D. Use of 4 side rails to restrict freedom

Explanation
The correct answer is 2 point soft restraint, Mittens, Use of 4 side rails to restrict freedom. These forms of restraints are considered non-violent because they aim to restrict movement and ensure safety without causing harm or pain to the individual. The 2 point soft restraint and mittens provide a gentle way to limit mobility, while the use of 4 side rails helps to confine the person within a designated space without the use of force.

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5.

Which of the following are considered forms of "Violent" restraints? (Select All that apply)

A.

Schedule dose of Geodon 20 mg by mouth for behavioral control
B.

Physical Holds
C.

One time dose of Geodon 20 mg administered IM (intramuscularly)
D.

Seclusion
E.

Four point double secured TAT (Twice as toughs) restraints

Correct Answer(s)
B. Physical Holds
C. One time dose of Geodon 20 mg administered IM (intramuscularly)
D. Seclusion
E. Four point double secured TAT (Twice as toughs) restraints

Explanation
The question asks for the forms of "Violent" restraints. "Physical Holds" can be considered a form of violent restraint as it involves physically restraining a person. "One time dose of Geodon 20 mg administered IM (intramuscularly)" is not a form of restraint, but it is included as a form of violent restraint because it involves administering medication for behavioral control. "Seclusion" is considered a form of violent restraint as it involves isolating a person in a confined space. "Four point double secured TAT (Twice as toughs) restraints" is also considered a form of violent restraint as it involves immobilizing a person using restraints.

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6.

In ensuring that safety is maintained and the least restrictive form of restraint is explored, which are the 2 best actions for the Nurse:

A.

Request an order for 4 point double secured (TAT) restraints from the Provider
B.

Requesting an order for a Physical hold from the Provider
C.

Requesting an order for Seclusion from the Provider
D.

Request a order for a chemical restraint as patient refused medications offered by mouth

Correct Answer(s)
C. Requesting an order for Seclusion from the Provider
D. Request a order for a chemical restraint as patient refused medications offered by mouth

Explanation
The two best actions for the nurse in ensuring safety and exploring the least restrictive form of restraint are requesting an order for seclusion from the provider and requesting an order for a chemical restraint as the patient refused medications offered by mouth. Seclusion can be used as a last resort when the patient's behavior poses an immediate threat to themselves or others, while a chemical restraint can be used when other forms of restraint are not feasible or appropriate.

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7.

What is the duration of an order for a Seclusion of this 10 year old patient?

A.

1 hour
B.

4 hours
C.

2 hours
D.

This patient cannot be placed in Seclusion due to age limit

Correct Answer
C. 2 hours

Explanation
The duration of an order for a Seclusion of this 10-year-old patient is 2 hours. This suggests that the patient can be placed in seclusion for a maximum of 2 hours as per the order.

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8.

The Nursing staff recognize that as a result of this restraint the following now apply (Select all that apply)

A.

The IPOC has to be modified to reflect this restraint
B.

The patient now requires a Constant observer
C.

The patient will remain on standard q15 minute observation
D.

An initiation of restraint/debrief note and Violent restraint Flowsheet documentation is now required
E.

An order must be placed and discontinued as appropriate for the restraint/restraints
F.

All of the above

Correct Answer(s)
A. The IPOC has to be modified to reflect this restraint
B. The patient now requires a Constant observer
D. An initiation of restraint/debrief note and Violent restraint Flowsheet documentation is now required
E. An order must be placed and discontinued as appropriate for the restraint/restraints

Explanation
The correct answer is all of the above. This means that all of the statements listed apply as a result of the restraint. The IPOC, or Individualized Plan of Care, needs to be modified to reflect the use of restraint. The patient now requires a Constant observer to ensure their safety. An initiation of restraint/debrief note and Violent restraint Flowsheet documentation is now required to document the use of restraint. Additionally, an order must be placed and discontinued as appropriate for the restraint/restraints used.

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9.

What is the duration of an order for Chemical restraint if given to this 10 year old

A.

2 hours
B.

3 hours
C.

1 hour
D.

A chemical restraint cannot be administered to a 10 year old

Correct Answer
C. 1 hour

Explanation
The correct answer is 1 hour because chemical restraint should only be used as a last resort and for the shortest duration necessary. In the case of a 10-year-old, it is important to minimize the use of chemical restraints due to their potential side effects and risks. Therefore, a shorter duration of 1 hour would be more appropriate in this situation.

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2021 Behavioral Health RN, Mhw, CNA Restraint Competency

A "Restraint" is defined as (select the best choice):

Only non-violent patients, legal guardians and immediate family members will be notified of the patient's rights regarding restraints/seclusion

Which of the following are considered "Non-violent" forms of restraints? Select All that apply

Which of the following are considered forms of "Violent" restraints? (Select All that apply)

In ensuring that safety is maintained and the least restrictive form of restraint is explored, which are the 2 best actions for the Nurse:

What is the duration of an order for a Seclusion of this 10 year old patient?

The Nursing staff recognize that as a result of this restraint the following now apply (Select all that apply)

What is the duration of an order for Chemical restraint if given to this 10 year old