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Question

Difficulty: EasyUse of Restraints and Safety Devices

A client on a medical-surgical unit becomes acutely restless and persistently attempts to leave the facility. Before considering the use of any restraints, which action should the practical nurse (PN) implement FIRST?

  1. A
    Apply a physical restraint immediately to ensure the client remains safely in the room.
  2. B
    Assume the restlessness is an expected age-related change and continue routine rounding.
  3. Provide a safe, repetitive diversionary activity such as folding towels to redirect the client's attention.Answer
  4. D
    Assign an unlicensed assistive personnel (UAP) to perform a comprehensive neurological assessment.

Answer

The PN should first provide a safe, repetitive diversionary activity to redirect the client's attention.
Providing a safe, repetitive diversionary activity, such as folding towels, is a non-pharmacological, least-restrictive alternative. It can safely redirect a restless client's attention and energy, thereby avoiding the immediate need for physical or chemical restraints while maintaining patient safety.

Step-by-Step Solution

1
Identify the client's immediate safety risk and behavioral change.
The client is acutely restless and attempting to leave the unit.
Recognizing the behavior dictates the need for a prompt, safe intervention.
2
Recall the principles of the least restrictive environment regarding restraint usage.
Physical or chemical restraints must be a last resort.
Nursing standards and laws require trying alternative, non-restrictive measures before applying any form of restraint.
3
Select the appropriate non-restrictive nursing intervention from the available choices.
Providing a diversionary activity is chosen as the first action.
Distraction techniques are a safe, within-scope, and effective first-line alternative to keep the client engaged and secure.

Key Concept

Least Restrictive Alternatives
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Topics

Use of Restraints and Safety Devices

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