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Difficulty: EasyAccident, Error, and Injury Prevention

A resident in a long-term care facility is frequently attempting to stand up from a wheelchair unassisted, posing a significant fall risk. Which action should the practical nurse take first to prevent injury?

  1. Provide the resident with a simple, engaging activity such as folding towels.Answer
  2. B
    Apply a soft lap belt to securely keep the resident seated in the wheelchair.
  3. C
    Document the restlessness as an expected, normal change associated with advanced age.
  4. D
    Instruct an unlicensed assistive personnel (UAP) to assess the resident for a possible urinary tract infection.

Answer

Provide the resident with a simple, engaging activity such as folding towels.
Providing a diversionary activity is a safe, non-restrictive intervention that redirects the resident's attention and reduces the desire to stand, thereby preventing falls while maintaining dignity and independence.

Step-by-Step Solution

1
Identify the primary safety risk presented in the scenario.
The resident is at high risk for falls and injury due to repeatedly attempting to stand unassisted.
Client safety is the immediate priority, requiring an intervention that prevents a fall.
2
Evaluate the available interventions based on the principle of the least restrictive environment.
A diversionary activity is selected because it is non-restrictive and effectively redirects the resident's energy.
Nursing standards mandate that less restrictive alternatives must be attempted before considering any physical or chemical restraints.

Key Concept

Least Restrictive Environment and Restraint Alternatives
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Topics

Accident, Error, and Injury Prevention

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