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Difficulty: MediumUse of Restraints and Safety Devices

An older adult client who recently returned from abdominal surgery is restless, disoriented, and continuously attempting to remove their surgical dressing. Which action should the practical nurse (PN) take first to protect the client while adhering to the principle of least restrictive interventions?

  1. Assess the client for underlying, reversible causes of the agitation, such as unmanaged pain or a full bladder.Answer
  2. B
    Contact the healthcare provider immediately to obtain a prescription for physical wrist restraints.
  3. C
    Document the disorientation as an expected, age-related cognitive response to the surgical procedure.
  4. D
    Administer a prescribed as-needed (PRN) intravenous (IV) push sedative to rapidly calm the client.

Answer

Assess the client for underlying, reversible causes of the agitation, such as unmanaged pain or a full bladder.
The correct action prioritizes the principle of least restrictive care. Before applying physical or chemical restraints, the nurse must systematically assess for and address underlying, reversible triggers of agitation. In postoperative older adult clients, unmanaged pain, hypoxia, and urinary retention are common, easily treatable causes of acute restlessness. Resolving these issues often eliminates the need for restraints entirely.

Step-by-Step Solution

1
Analyze the clinical scenario
The client is an older adult exhibiting acute postoperative restlessness and agitation, posing a direct risk to their surgical site.
Understanding the patient's presentation helps prioritize safe and ethical nursing actions.
2
Apply the principle of least restrictive interventions
The nurse must identify and attempt to resolve underlying causes of agitation before considering restrictive measures.
Physical and chemical restraints are interventions of last resort due to their associated physical and psychological risks.
3
Determine the initial nursing action
Assessing for basic physiological needs, such as acute pain, hypoxia, or urinary retention, is the most appropriate first step.
Treating the root cause often resolves the behavioral issue completely without the need for any physical or chemical restraints.

Key Concept

Prioritizing least restrictive alternatives and identifying reversible causes of acute agitation.
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Topics

Use of Restraints and Safety Devices

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