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Question

Difficulty: MediumUse of Restraints and Safety Devices

A client recovering from a hip arthroplasty begins experiencing severe disorientation during the evening shift and repeatedly attempts to climb out of bed. The client's spouse is highly anxious and asks the nursing staff to apply physical restraints to prevent a fall. Which initial action should the practical nurse (PN) take?

  1. Relocate the client to a room near the nurses' station to allow for frequent observation.Answer
  2. B
    Contact the healthcare provider immediately to obtain a prescription for bilateral wrist restraints.
  3. C
    Reassure the spouse that sudden confusion is a normal, temporary response for older adults.
  4. D
    Delegate the application of a safety vest to the unlicensed assistive personnel.

Answer

The correct action is to relocate the client to a room near the nurses' station for frequent observation.
The correct answer identifies a primary nursing responsibility: implementing the least restrictive measures possible to ensure client safety. Relocating a disoriented client closer to the nurses' station allows for frequent visual monitoring and quick intervention, which is a standard restraint alternative that must be attempted before physical devices are utilized.

Step-by-Step Solution

1
Analyze the client's behavior and the spouse's request.
The client is at high risk for falls due to acute disorientation, and the spouse is requesting physical restraints.
Understanding the clinical priority (fall prevention) versus the requested intervention (restraints) is essential for safe practice.
2
Evaluate the standard of care regarding physical restraints.
Standards mandate that restraints must always be the intervention of last resort.
Using least restrictive measures first protects client autonomy and reduces the risk of restraint-related injuries.
3
Identify the least restrictive intervention among the choices provided.
Moving the client near the nurses' station provides the necessary supervision without restricting the client's physical movement.
Increased observation is a recognized and effective alternative to physical restraints.

Key Concept

Restraint Alternatives and Least Restrictive Measures
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Topics

Use of Restraints and Safety Devices

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