Examkin

Question

Difficulty: MediumAccident, Error, and Injury Prevention

During a shift, a practical nurse (PN) finds a client with a history of generalized weakness wandering the unit hallway barefoot. The client is visibly confused about the location of their room. Which of the following actions should the PN take to promote safety and prevent injury? Select all that apply.

  1. Escort the client safely back to their room and gently reorient them to their surroundings.Answer
  2. Assist the client in putting on non-slip footwear to reduce the immediate risk of a fall.Answer
  3. C
    Ask passing visitors in the hallway if they recognize the client to quickly locate their room.
  4. D
    Apply a soft belt restraint to the client's chair once returned to the room to prevent further wandering.
  5. Ensure the client's room environment is well-lit and the floor is free of clutter.Answer
  6. F
    Assume the disorientation is a normal aspect of aging and omit reporting it to the charge nurse.

Answer

The correct actions are to escort and reorient the client, assist them with non-slip footwear, and ensure their room is well-lit and clutter-free.
The correct interventions focus on immediate hazard reduction and promoting a safe environment using the least restrictive methods. Providing non-slip footwear directly addresses the physical risk of falling while barefoot. Guiding the client back to a familiar room, providing gentle reorientation, and ensuring the space is well-lit and clutter-free are proactive environmental safety measures that protect the client from injury without compromising their dignity or independence.

Step-by-Step Solution

1
Identify the immediate safety hazards presented in the scenario.
The client is at high risk for a fall due to weakness and walking barefoot, and is at risk for environmental injury due to confusion and wandering.
Recognizing physical and cognitive risk factors is the first step in prioritizing safety interventions.
2
Select interventions that immediately address the physical and environmental risks.
Providing non-slip footwear addresses the physical fall risk. Escorting the client to their room, reorienting them, and ensuring a well-lit, clutter-free environment address the environmental hazards.
Nurses must implement proactive, least restrictive measures to maintain a safe care environment.
3
Eliminate interventions that violate safety, legal, or ethical standards.
Using restraints, breaching confidentiality by asking visitors, and dismissing the confusion as normal aging are incorrect and unsafe actions.
These actions violate the principles of least restrictive care, HIPAA regulations, and proper clinical judgment regarding acute delirium.

Key Concept

Fall Prevention and Safety Promotion
Rate this question

Topics

Accident, Error, and Injury Prevention

More questions from this topic