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Difficulty: HardAccident, Error, and Injury Prevention

A practical nurse (PN) is caring for a 79-year-old client admitted with severe dehydration and a methicillin-resistant *Staphylococcus aureus* (MRSA) wound infection. The client, who requires contact precautions, exhibits sudden, intense restlessness and attempts to forcefully remove their peripheral intravenous (IV) catheter. Which action should the PN take FIRST?

  1. A
    Apply soft bilateral wrist restraints immediately to protect the IV access, then contact the provider for a prescription.
  2. B
    Instruct the unlicensed assistive personnel (UAP) to sit with the client and evaluate the patency of the IV site.
  3. Stay with the client to provide verbal redirection while assessing for potential physiological causes of the agitation.Answer
  4. D
    Reassure the client's visiting family members that acute confusion is an expected, age-related change.

Answer

The correct action is to stay with the client to provide verbal redirection while assessing for potential physiological causes of the agitation.
The correct action prioritizes client safety using the least restrictive method possible. By remaining at the bedside, the PN prevents the immediate injury (removal of the IV). Simultaneously, assessing for a physiological cause addresses the underlying trigger of the acute delirium, which is the standard of care for sudden behavioral changes.

Step-by-Step Solution

1
Identify the immediate safety threat and the nature of the client's behavior.
The client is experiencing sudden, acute restlessness and is at immediate risk of injuring themselves by pulling out an IV catheter.
Recognizing the acuity of the situation dictates the urgency and type of intervention required.
2
Apply the principle of least restrictive interventions.
Direct observation and verbal de-escalation are chosen over physical restraints.
Nursing standards mandate that the least restrictive measures must be exhausted before applying physical or chemical restraints.
3
Differentiate between chronic cognitive decline and acute delirium.
The nurse recognizes that sudden confusion in an older adult is abnormal and investigates underlying physical causes (e.g., hypoxia, electrolyte imbalance from dehydration).
Treating the underlying physiological trigger often resolves the behavioral agitation safely and effectively.

Key Concept

Prioritization of least restrictive safety measures and immediate physiological assessment for acute delirium.
Estimated Time:1m 15s
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Topics

Accident, Error, and Injury Prevention

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