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Difficulty: MediumAccident, Error, and Injury Prevention

An older adult client is admitted to the medical-surgical unit with severe dehydration. The client, who has generalized weakness, suddenly becomes disoriented and repeatedly attempts to get out of bed unassisted. Which of the following actions should the practical nurse (PN) take to ensure safety and prevent injury? (Select all that apply.)

  1. Position the bed at its lowest possible height with the wheels securely lockedAnswer
  2. B
    Apply soft bilateral wrist restraints to stop the client from unassisted ambulation
  3. Clear the pathway between the bed and the bathroom of all medical equipment and clutterAnswer
  4. D
    Document the sudden onset of disorientation as an expected age-related cognitive change
  5. Offer the client assistance with toileting at regular, scheduled intervalsAnswer

Answer

The correct safety interventions are positioning the bed at its lowest locked height, clearing the pathway of clutter, and offering scheduled toileting assistance.
Ensuring the bed is in the lowest locked position, removing environmental hazards, and providing proactive toileting assistance are evidence-based, non-restrictive interventions that directly mitigate the risk of falls and injury for a disoriented, weak client.

Step-by-Step Solution

1
Assess the client's current risk factors for injury.
The client has generalized weakness, sudden disorientation, and is attempting to ambulate unassisted, indicating a high risk for falls.
Identifying specific risk factors directs the selection of appropriate environmental and physical safety interventions.
2
Select non-restrictive safety measures that address the identified risks.
Appropriate measures include lowering the bed, removing tripping hazards, and anticipating basic needs like toileting.
Least restrictive alternatives must always be implemented prior to considering physical restraints.
3
Identify clinical findings that require further medical evaluation.
The sudden onset of disorientation is recognized as a sign of acute delirium, not normal aging.
Prompt recognition of acute changes ensures underlying causes (like severe dehydration) are treated rather than dismissed.

Key Concept

Implementing least-restrictive environmental safety measures and recognizing acute changes in older adults.
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Topics

Accident, Error, and Injury Prevention

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