During evening rounds at a continuous care retirement community, a practical nurse observes that a 79-year-old resident is newly disoriented, highly agitated, and repeatedly attempting to climb over the bed rails. Which actions should the nurse take? (Select all that apply.)
- Evaluate the resident for underlying sources of discomfort, such as a localized infection or hypoxia.Answer
- BReassure the family that sudden cognitive decline is a standard physiological consequence of growing older.
- CSecure a vest restraint to ensure the resident does not sustain a fall injury from the bed.
- Place the resident's mattress closer to the floor or use specialized fall mats next to the bed.Answer
- Assign a staff member to provide one-to-one supervision until the resident's safety can be assured.Answer
- FRequest an immediate prescription for an antipsychotic medication to manage the disruptive behavior.
Answer
The correct actions are to evaluate the resident for underlying physiological issues, place the mattress closer to the floor with fall mats, and assign a staff member for direct supervision.
The correct interventions prioritize client safety using the least restrictive methods (such as lowering the bed, using fall mats, and providing a sitter) while actively assessing for an underlying physiological cause for the acute confusion, which is a hallmark of delirium in older adults.
Step-by-Step Solution
Key Concept
Prioritizing Restraint Alternatives and Recognizing Delirium