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Difficulty: MediumAccident, Error, and Injury Prevention

A 78-year-old client who is two days post-operative suddenly becomes extremely agitated, disoriented, and repeatedly attempts to pull off their surgical dressing. Which actions should the practical nurse implement to prevent injury and promote client safety? Select all that apply.

  1. Relocate the client to a room that is highly visible from the nurses' station.Answer
  2. B
    Apply bilateral soft wrist restraints to immediately protect the surgical site.
  3. Evaluate the client's vital signs and oxygen saturation levels.Answer
  4. D
    Document the disorientation as an expected cognitive change related to advanced age.
  5. Request that a familiar family member stay at the bedside to provide calm reassurance.Answer
  6. F
    Delegate the ongoing neurological assessment of the client's behavioral changes to the assistive personnel.

Answer

The correct actions are to relocate the client closer to the nurses' station, evaluate vital signs and oxygen saturation, and request a family member to stay at the bedside.
The correct actions prioritize a safe environment using the least restrictive methods possible. Relocating the client to a visible room and having family present provide necessary supervision and comfort without physical restriction. Additionally, sudden agitation and confusion are often the first signs of physiological decline (such as hypoxia or infection) in older adults, making the assessment of vital signs and oxygenation a critical priority.

Step-by-Step Solution

1
Identify the immediate safety risk.
The agitated client is at risk of harming themselves by pulling off their surgical dressing.
Recognizing the risk guides the selection of interventions that protect the client while honoring their rights.
2
Select least-restrictive interventions.
Moving the client to a visible room and asking family to stay at the bedside are chosen.
Restraints must always be a last resort. Continuous observation and environmental modifications safely manage behavior without restricting freedom.
3
Investigate physiological causes of sudden behavioral changes.
Vital signs and oxygen saturation are evaluated.
Acute confusion (delirium) in older adults is frequently caused by hypoxia, infection, or physiological distress, requiring immediate clinical assessment rather than assumption of age-related cognitive decline.

Key Concept

Prioritizing least-restrictive safety measures and investigating physiological causes for acute confusion.
Estimated Time:1m 30s
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Topics

Accident, Error, and Injury Prevention

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