Restraints
When can restraints be used on a 5150 patient?
if the patient is a danger to themselves OR a danger to other. Sometimes it will be both!
Why should the LVN maintain safe distance?
Reduces perceived threat and keeps staff safe.
What is one professional boundary violation seen a lot in hospital settings?
Sharing personal problems with a patient
Side effects of Serotonin Syndrome
Nausea
Insomnia
Sexual dysfunction
Anxiety (early)
A patient reports dizziness after receiving medication. What is the LVN’s FIRST action?
Check vital signs
An LVN can independently order restraints
True or False
False, restraints must be ordered by an MD
List a few non-threatening body language techniques
Open posture
Hands visible
Avoid crossed arms or pointing
Stay at eye level (not towering)
A patient offers the LVN an expensive gift at discharge. What is the best response?
Politely decline and explain facility policy
Anticholinergic effect symptoms are:
Dry mouth, constipation, urinary retention, blurred vision
Which phase of the nursing process includes administering medications?
Implementation
Which action should be attempted before applying restraints?
Restraints are a last resort. Always try least restrictive interventions first.
What are some ways to reduce stimulation in a clients' room?
Dim lights
Lower noise
Remove unnecessary people
Move to a quieter area if safe
Which behavior may indicate boundary crossing that was earlier explained?
Staying late frequently to visit one specific patient
Name the 2 common Benzodiazepines
Lorazepam (Ativan)
Diazepam (Valium)
Which task is outside the LVN scope?
Creating nursing diagnoses
How often should a restrained patient be assessed?
Patients in restraints must be assessed at least every 2 hours for:
Circulation
Skin integrity
Nutrition/hydration
Elimination needs
Range of motion
A patient is yelling and pacing in the hallway. What is the LVN’s best initial action?
verbal de-escalation
Which touch is appropriate within professional boundaries?
Holding a patient’s hand during a painful procedure
Which teaching is most important for a patient taking lithium?
Drink plenty of fluids
The nurse determines the patient’s pain has decreased from 8/10 to 3/10. Which step is this?
Evaluation
Where should restraints be tied?
Restraints must be tied to the bed frame, not side rails, to prevent injury if the bed moves.
Which statement demonstrates appropriate limit setting?
A. “You’re being inappropriate.”
B. “If you keep yelling, you’ll be restrained.”
C. “I want to help, but I can’t allow threats.”
D. “Calm down or leave.”
Answer: C
Which principle best guides professional boundaries?
The nurse-patient relationship must always be therapeutic, not personal.
A patient on antidepressants states, “I feel worse after one week.” What is the best response?
“This medication takes a few weeks to work.”
If a patient’s condition worsens after an intervention, what should the LVN do?
Reassess and report to RN