Examkin

Question

Difficulty: MediumUse of Restraints and Safety Devices

A client on a medical-surgical unit is experiencing acute confusion and repeatedly attempts to climb out of bed without assistance, posing a high risk for a fall. Which action should the practical nurse (PN) implement FIRST?

  1. Activate a bed exit alarm and lower the bed to the lowest possible position.Answer
  2. B
    Obtain a prescription from the health care provider for an as-needed (PRN) physical restraint.
  3. C
    Assume the acute confusion is a normal part of the aging process and continue routine monitoring.
  4. D
    Delegate hourly neurological assessments to the unlicensed assistive personnel (UAP).

Answer

Activate a bed exit alarm and lower the bed to the lowest possible position.
The correct action prioritizes client safety while adhering to the core clinical principle of using the least restrictive means possible. Implementing a bed alarm and placing the bed in the lowest position protects the client from severe fall injuries without inappropriately restricting their movement.

Step-by-Step Solution

1
Analyze the client's immediate safety risk.
The client is confused and attempting to exit the bed unassisted, which creates an imminent risk for a fall and injury.
Identifying the primary threat to the client allows the nurse to prioritize interventions.
2
Determine the most appropriate intervention based on the principle of least restrictive restraints.
Using a bed alarm and lowering the bed ensures safety without restricting the client's physical freedom.
Nursing standards mandate that non-restraint alternatives must be attempted and documented before considering physical or chemical restraints.

Key Concept

Restraint Alternatives and Client Safety
Rate this question

Topics

Use of Restraints and Safety Devices

More questions from this topic