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Difficulty: MediumUse of Restraints and Safety Devices

While rounding on a medical-surgical unit, a practical nurse observes that a 72-year-old individual who recently had intestinal surgery is suddenly highly disoriented and aggressively trying to climb over the bed rails. An assistive staff member recommends immediately securing the client's wrists to prevent a dangerous fall. Which nursing intervention is the initial priority?

  1. Move the client to a room with high visibility for continuous monitoring.Answer
  2. B
    Telephone the attending provider to obtain an emergency prescription for soft wrist restraints.
  3. C
    Direct the assistive staff member to apply the protective devices while the nurse gathers documentation forms.
  4. D
    Document the sudden disorientation as a routine age-related change and darken the room to promote sleep.

Answer

Move the client to a room with high visibility for continuous monitoring.
The correct answer correctly identifies that the nurse must prioritize the least restrictive environment. Moving the client to a highly visible area provides necessary supervision to prevent falls without unnecessarily restricting the client's freedom of movement.

Step-by-Step Solution

1
Assess the client's immediate safety and the nature of the behavioral change.
The client is experiencing sudden acute confusion and poses a fall risk.
Sudden confusion requires both immediate safety measures and a subsequent investigation for underlying causes like infection or hypoxia.
2
Evaluate the recommendation to apply physical restraints.
Physical restraints are identified as a last resort.
Standards of care and legal guidelines require that all less restrictive alternatives be exhausted before chemical or physical restraints are utilized.
3
Select the least restrictive intervention that ensures patient safety.
Continuous monitoring and relocation closer to the nursing station are chosen.
Direct observation protects the client from falling while avoiding the physical and psychological risks associated with restraints.

Key Concept

Restraint Alternatives and Least Restrictive Environment
Estimated Time:1m 0s
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Topics

Use of Restraints and Safety Devices

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