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Question

Difficulty: EasyAccident, Error, and Injury Prevention

Upon admission to an acute care unit, an elderly client with advanced cataracts demonstrates difficulty navigating the unfamiliar hospital room. Which nursing intervention is the priority for preventing accidental falls for this individual?

  1. Maintain a clutter-free environment and ensure the pathway to the bathroom is well-lit.Answer
  2. B
    Request an order for bilateral wrist restraints to keep the client safely in bed overnight.
  3. C
    Delegate the task of assessing the client's exact level of visual impairment to an unlicensed assistive personnel.
  4. D
    Document the client's disorientation to the room as an expected finding of normal cognitive aging.

Answer

The priority intervention is to maintain a clutter-free environment and ensure adequate lighting.
For a client with visual impairment, the most effective and immediate way to prevent falls is to optimize the physical environment. Keeping pathways clear of obstacles and adequately illuminated directly mitigates the risks associated with poor vision.

Step-by-Step Solution

1
Identify the primary risk factor threatening the client's safety.
The client has a significant sensory deficit (advanced cataracts) and is in an unfamiliar setting.
Recognizing specific vulnerabilities is essential for selecting the correct preventative intervention.
2
Select the least restrictive, most immediate environmental modification.
Clearing the room of clutter and illuminating the pathway to the bathroom is chosen.
This action immediately compensates for poor vision and removes physical tripping hazards, keeping the client safe without using improper restraints.

Key Concept

Fall Prevention in Sensory Impairment
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Topics

Accident, Error, and Injury Prevention

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