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Difficulty: EasyAccident, Error, and Injury Prevention

A client with moderate dementia is admitted to a medical-surgical unit and repeatedly attempts to get out of bed unassisted. The client has an unsteady gait and is at high risk for falls. Which intervention should the practical nurse (PN) implement to prevent injury while utilizing the least restrictive environment?

  1. Place a pressure-sensitive bed alarm under the client's mattress.Answer
  2. B
    Raise all four side rails on the client's bed.
  3. C
    Request a prescription for a sedative medication to promote sleep.
  4. D
    Delegate the unlicensed assistive personnel (UAP) to assess the client's risk for falls.

Answer

Place a pressure-sensitive bed alarm under the client's mattress.
Placing a bed alarm is the most appropriate and direct intervention because it promotes safety by alerting staff to the client's movement while strictly maintaining the least restrictive environment possible.

Step-by-Step Solution

1
Identify the primary safety risk and the client's clinical profile.
The client is at high risk for falls due to an unsteady gait and moderate dementia.
Understanding the specific risk and cognitive status is necessary to select a safe, targeted intervention.
2
Evaluate the available interventions against the principle of least restrictive care.
A bed alarm provides an early warning system without restricting the client's physical freedom.
Physical and chemical restraints should only be used as a last resort after less restrictive alternatives have failed.

Key Concept

Implementing least restrictive alternatives to prevent falls and client injury.
Estimated Time:1m 0s
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Topics

Accident, Error, and Injury Prevention

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