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Question

Difficulty: HardUse of Restraints and Safety Devices

The healthcare team is caring for a 72-year-old client receiving intravenous antibiotics for sepsis. During the shift, the client becomes acutely disoriented and repeatedly grasps at the peripheral intravenous (IV) tubing. The primary registered nurse (RN) is currently assisting another unstable client. Which action should the practical nurse (PN) take first?

  1. Assign an available assistive personnel to remain in the room and attempt to verbally redirect the client's behavior.Answer
  2. B
    Contact the healthcare provider to request a prescription for soft wrist restraints to be used as needed for agitation.
  3. C
    Attribute the sudden disorientation to age-related cognitive decline and secure the IV tubing tightly against the client's arm.
  4. D
    Apply temporary soft wrist restraints immediately and delegate the hourly neurovascular assessments to the assistive personnel.

Answer

Assign an available assistive personnel to remain in the room and attempt to verbally redirect the client's behavior.
The correct answer demonstrates the fundamental principle of using the least restrictive alternative. Before applying physical restraints, the nursing staff must attempt and document alternative measures. Providing 1:1 observation and attempting verbal redirection protects the client's safety while preserving their autonomy and adhering to legal requirements.

Step-by-Step Solution

1
Analyze the client's presentation and safety risk.
The client is acutely disoriented and at risk of dislodging an essential medical device (IV tubing).
Identifying the primary safety threat determines the urgency and type of intervention needed.
2
Evaluate the legal and ethical guidelines regarding restraint application.
Standards require that the least restrictive non-physical interventions be implemented and documented before moving to restraints.
Restraints restrict a client's freedom and carry significant physical and psychological risks.
3
Select the intervention that best aligns with the least restrictive alternative principle.
Assigning a sitter (assistive personnel) to provide 1:1 observation and verbal redirection is the most appropriate initial action.
This strategy addresses the immediate safety risk without resorting to physical immobilization, adhering strictly to the standard of care.

Key Concept

Least Restrictive Restraint Alternatives
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Topics

Use of Restraints and Safety Devices

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