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Difficulty: MediumAccident, Error, and Injury Prevention

During a shift at a residential care facility, a resident with a baseline of mild cognitive impairment suddenly becomes highly agitated and attempts to climb over the dining tables. The resident is unsteady on their feet and at immediate risk for a fall. Which action should the practical nurse (PN) implement first to prevent injury?

  1. Escort the resident to a quiet, closely monitored environment away from the busy dining area.Answer
  2. B
    Secure the resident in a heavy stationary chair using a quick-release lap belt.
  3. C
    Document the sudden behavioral change as an expected progression of the resident's cognitive decline.
  4. D
    Instruct the unlicensed assistive personnel (UAP) to perform an immediate neurological assessment.

Answer

The correct action is to escort the resident to a quiet, closely monitored environment away from the busy dining area.
The correct action prioritizes immediate client safety using the least restrictive alternative available. Relocating the resident to a quiet, supervised area protects them from falling over the furniture while simultaneously removing them from the potentially overstimulating environment that may be triggering the acute agitation.

Step-by-Step Solution

1
Assess the immediate environment and the client's risk for injury.
The resident is unsteady and actively attempting a dangerous maneuver (climbing tables), indicating a high, imminent fall risk.
Immediate physical safety is the highest priority in a behavioral crisis.
2
Determine the least restrictive intervention to ensure safety.
Removing the client from the overstimulating environment and providing close supervision addresses the behavior without using restraints.
Nursing standards mandate the use of least restrictive alternatives before considering physical or chemical restraints.
3
Plan for follow-up assessment.
Once the client is safe, the nurse must investigate the underlying cause of the sudden agitation (e.g., delirium, infection, or pain).
Sudden changes in cognition are acute medical events, not normal aging.

Key Concept

Least Restrictive Safety Interventions and Delirium Recognition
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Topics

Accident, Error, and Injury Prevention

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