The Ties That Bind
Medical necessity such as drug or alcohol withdrawal, mechanical ventilation, or pulling at medical devices may require this type of restraint order.
What is Non-Violent Restraint order?
Test most often used to assess level of consciousness.
What is the Glasgow Coma Scale?
The normal range of findings on a glucometer.
What is 74-106 mg/dL?
Resonant, hyperresonant, tympany, and dullness
What are sounds you hear when percussing?
The 5 rights of delegation
What are right task, right circumstance, right person, right directions/communication, and right supervision and evaluation?
Restraints must be secured to this type of bed part.
What is non-moveable?
This comes from a direct blow that causes rotation of the brain inside the skull and shear injury.
What is a concussion?
Critical values found on the glucometer.
What is <40 mg/dL or >400 mg/dL?
The medical term for a collection of blood under the skin
What is ecchymosis?
The federal law that protects health information
What is HIPAA (must spell it correctly to get points)?
This cranial nerve is assessed by having a patient clench their teeth.
What is the Trigeminal Nerve or Cranial Nerve V?
This is a nursing intervention for hypoglycemia that does not require a physician's order.
What is provide the patient with juice?
The abnormal skin assessment you might expect to find in a patient with heart failure
What is edema?
The 5 rights of medication administration
What are right patient, right medication, right dose, right route, and right time?
The nurse should always use this type of restraint.
What is the least restrictive method?
This is what PERRLA stands for.
What is pupils equal, round, reactive to light and accommodation?
Signs and symptoms of hyperglycemia
What are dehydration, urine ketones, and acetone breath?
The abnormal respiratory assessment finding you would expect to find in a patient with Tuberculosis
What is hemoptysis?
The type of isolation precautions necessary for C. Diff
What is contact?
These six things must all be assessed frequently when a patient is in restraints.
What is respiratory status, circulation, skin, pain, range of motion, need for bathroom?
The assessment process for accommodation.
What is ask the person to focus on a distant object which should dilate the pupils; then have the person shift the gaze to a near object such as your finger held about 7 to 8 cm (3 inches) from the person's nose which should elicit a normal response of pupillary constriction, and convergence of the axes of the eyes?
Signs and symptoms of hypoglycemia
What are cool, clammy skin; nervousness; confusion; and weakness?
Normal ranges of Hemoglobin for males and females
What are 14-18 and 12-16?
A requirement for every specimen sample
What is a patient label?