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Difficulty: MediumAccident, Error, and Injury Prevention

A resident in a long-term care facility is receiving treatment for a urinary tract infection. During the evening shift, the resident becomes highly agitated, paces the hallways, and repeatedly attempts to open the secured exit doors. Which actions should the practical nurse implement to ensure the resident's safety? Select all that apply.

  1. A
    Apply a vest restraint to keep the resident safely seated in a chair.
  2. Redirect the resident to a quiet, supervised area with a simple, familiar activity.Answer
  3. C
    Document the sudden behavioral changes as an expected progression of the aging process.
  4. Ensure the resident's walking path is well-lit and clear of clutter.Answer
  5. E
    Instruct an unlicensed assistive personnel (UAP) to independently assess the resident's neurological status.
  6. Assign a staff member to provide continuous one-to-one observation.Answer

Answer

The correct actions are to redirect the resident to a quiet area with a familiar activity, ensure the walking path is well-lit and clear of clutter, and assign a staff member to provide continuous one-to-one observation.
The correct interventions prioritize client safety while strictly adhering to the principle of using the least restrictive environment. Redirecting the client, removing environmental hazards, and implementing continuous observation prevent falls and elopement without inappropriately resorting to physical restraints.

Step-by-Step Solution

1
Identify the primary safety risks associated with the resident's behavior.
The resident is agitated, pacing, and attempting to exit the facility, which creates a high risk for elopement, falls, and injury.
Recognizing specific hazards determines which interventions will be most effective and urgently needed.
2
Select interventions that prioritize safety using the least restrictive methods.
Redirection, modifying the environment to remove hazards, and providing one-to-one observation directly address the safety risks without unlawfully restricting the resident's freedom.
Nursing standards require exhausting all non-pharmacological and non-physical restraint alternatives first.
3
Eliminate inappropriate or out-of-scope actions.
Applying a vest restraint, assuming the behavior is normal aging, and delegating complex assessments to a UAP are eliminated.
These actions violate restraint protocols, demonstrate a failure to recognize acute delirium, and breach delegation guidelines.

Key Concept

Prioritizing least restrictive interventions and environmental safety for an agitated, wandering client.
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Topics

Accident, Error, and Injury Prevention

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