Examkin

Question

Difficulty: HardAccident, Error, and Injury Prevention

Upon entering the room of an 82-year-old individual admitted with urosepsis, the practical nurse (PN) discovers the client attempting to climb over the raised side rails. The client, who was fully oriented during the shift report two hours prior, is now severely agitated, diaphoretic, and shouting at unseen individuals in the corner of the room. What is the priority intervention to prevent injury?

  1. Remain at the bedside to ensure immediate physical safety while calling out for a colleague to notify the charge nurse of the acute change.Answer
  2. B
    Secure bilateral soft wrist restraints to the bed frame immediately to prevent a catastrophic fall from the bed.
  3. C
    Dim the overhead lights and document the behavior as a typical manifestation of age-related nighttime disorientation.
  4. D
    Perform an independent comprehensive neurological assessment to determine the precise etiology of the altered mental status.

Answer

The priority is to remain with the client to provide immediate physical safety and verbal de-escalation, while simultaneously delegating the task of notifying the RN for a comprehensive assessment of the acute change.
When a client experiences an acute change in mental status and is at immediate risk for a fall, the priority is to maintain continuous observation and physical presence. This ensures safety using the least restrictive method possible. Because this is an acute, sudden change indicating potential medical deterioration (delirium secondary to urosepsis), the RN must be notified immediately to conduct a comprehensive assessment.

Step-by-Step Solution

1
Analyze the clinical presentation.
The client has transitioned from oriented to severely agitated and hallucinating within two hours. This rapid onset indicates acute delirium, likely secondary to urosepsis.
Recognizing the difference between acute delirium and chronic dementia dictates the urgency of the medical response.
2
Evaluate the immediate risk to the client.
The client is actively attempting to climb over the bed rails, presenting an imminent risk for a severe fall and injury.
Safety is the highest priority in the hierarchy of nursing care.
3
Apply the principles of least restrictive interventions.
Physical restraints must be the absolute last resort. Continuous human observation and verbal redirection must be utilized first.
Regulatory standards and ethical practice mandate exhausting all alternatives before applying restraints.
4
Determine the appropriate scope of practice action.
The PN must secure the client physically by staying at the bedside, but must alert the RN because a comprehensive assessment of an acute, unstable change is required.
The PN contributes to the plan of care and gathers data, but the RN is responsible for the initial comprehensive assessment of an acute deterioration.

Key Concept

Prioritizing least restrictive safety measures and recognizing acute delirium within the PN scope of practice.
Rate this question

Topics

Accident, Error, and Injury Prevention

More questions from this topic