Examkin

Question

Difficulty: MediumAccident, Error, and Injury Prevention

A practical nurse (PN) on a medical-surgical unit is caring for an older adult client with Alzheimer's disease who is hospitalized for dehydration. The client is confused, highly restless, and repeatedly tries to climb out of bed. Which action should the PN take to ensure the client's safety while utilizing the least restrictive intervention?

  1. A
    Raise all four side rails on the bed to provide a continuous physical barrier.
  2. B
    Request a prescription for an as-needed sedative to reduce the client's restlessness.
  3. Lower the bed to its lowest position and place a high-impact fall mat on the floor beside it.Answer
  4. D
    Transfer the client to a geriatric chair with a locked lap tray attached.

Answer

The correct action is to lower the bed to its lowest setting and place a high-impact fall mat beside it.
Lowering the bed and placing a fall mat on the floor are evidence-based, non-restrictive interventions. These actions do not limit the client's freedom of movement—therefore they are not restraints—but they significantly reduce the distance of a potential fall and cushion the impact, directly preventing severe injury.

Step-by-Step Solution

1
Analyze the client's behavior and associated risk factors.
The client is confused, restless, and at high risk for falls due to repeatedly attempting to climb out of bed.
Identifying the specific safety threat is the essential first step in clinical decision-making.
2
Evaluate the proposed interventions against the principle of least restrictive care.
Side rails, sedatives, and locked trays all act as physical or chemical restraints, which limit freedom of movement.
Nurses are legally and ethically mandated to exhaust all less restrictive alternatives before applying any form of restraint.
3
Select the intervention that promotes safety without functioning as a restraint.
Lowering the bed and using a fall mat prevents severe injury while maintaining the client's freedom of movement.
This approach aligns with evidence-based safety standards for managing restless clients with cognitive impairment.

Key Concept

Restraint Alternatives and Fall Injury Prevention
Estimated Time:1m 0s
Rate this question

Topics

Accident, Error, and Injury Prevention

More questions from this topic