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Difficulty: EasyUse of Restraints and Safety Devices

While rounding on an assigned unit, a practical nurse (PN) notices that an older adult client with acute delirium is actively trying to climb over the lowered side rails of the bed. The bed is maintained in its lowest position. To ensure safety using the least restrictive method, which intervention is most appropriate?

  1. A
    Raise and secure all four side rails on the client's bed.
  2. B
    Inform the family that the sudden confusion is a normal part of the aging process.
  3. Place a pressure-sensitive alarm pad on the client's mattress.Answer
  4. D
    Accept delegation from the registered nurse (RN) to administer an intravenous push sedative.

Answer

The most appropriate intervention is to place a pressure-sensitive alarm pad on the client's mattress.
Placing a pressure-sensitive alarm pad on the mattress is the correct action because it is a non-invasive, least-restrictive alternative to physical restraints. It alerts the nursing staff when the client attempts to exit the bed, promoting safety while preserving the client's physical freedom and dignity.

Step-by-Step Solution

1
Identify the primary safety risk and the required level of intervention.
The client is at high risk for falls due to delirium, necessitating a safety intervention.
Recognizing the risk is the first step in the nursing process for client safety.
2
Apply the principle of least restrictive environment.
Physical and chemical restraints must be avoided if alternative methods have not been attempted.
Nursing standards and federal regulations mandate trying least restrictive alternatives before utilizing restraints.
3
Select the intervention that maximizes safety without restricting movement.
A bed alarm is selected because it alerts staff to movement without binding the client.
Bed alarms are recognized as a highly effective first-line restraint alternative.

Key Concept

Restraint Alternatives and Safety Devices
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Topics

Use of Restraints and Safety Devices

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