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Question

Difficulty: MediumAccident, Error, and Injury Prevention

Following a scheduled total knee replacement, a client with no previous history of cognitive impairment begins shouting at staff and aggressively removing their surgical dressings. The client's partner states that this behavior is just a normal part of getting older. Which intervention should the nurse implement first to ensure client safety?

  1. Remain at the bedside to physically redirect the client's hands while assessing vital signs and oxygen saturation.Answer
  2. B
    Reassure the partner that temporary disorientation is a standard, expected occurrence for aging clients after anesthesia.
  3. C
    Apply bilateral soft wrist restraints to immediately protect the surgical wound and maintain intravenous access.
  4. D
    Instruct an unlicensed assistive personnel to sit with the client while the nurse reviews the chart for a sedative prescription.

Answer

The nurse should remain with the client to prevent immediate injury through physical redirection while assessing for acute physiological causes of the sudden behavioral change, such as hypoxia.
Remaining at the bedside ensures immediate safety by physically redirecting the client's hands away from the surgical site, representing a least-restrictive intervention. Simultaneously assessing vital signs and oxygen saturation addresses the potential underlying physiological cause of the sudden confusion, such as hypoxia or an adverse medication reaction.

Step-by-Step Solution

1
Analyze the client's presentation and the partner's statement.
Identify that the sudden onset of agitation and confusion indicates acute delirium, not normal aging.
Recognizing the difference between normal aging and acute delirium is crucial for identifying an underlying medical emergency.
2
Evaluate the safety risks and prioritize interventions.
Determine that the immediate risk is self-injury to the surgical site and intravenous lines.
The priority is always to secure the client's airway, breathing, circulation, and immediate physical safety.
3
Select the safest, most appropriate nursing action.
Choose to stay with the client to provide direct supervision, use least restrictive physical redirection, and assess vital signs.
This avoids premature use of restraints, prevents inappropriate delegation of an unstable client, and initiates the assessment of the root cause.

Key Concept

Prioritization of least restrictive safety measures and assessment in acute delirium.
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Topics

Accident, Error, and Injury Prevention

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