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Difficulty: EasyAccident, Error, and Injury Prevention

A client with bilateral cataracts and generalized weakness is admitted to a medical unit for observation. Which interventions should the practical nurse implement to minimize the client's risk of injury? (Select all that apply)

  1. Place the client's bed in the lowest position with the wheels locked.Answer
  2. Ensure the call light and personal items are within the client's easy reach.Answer
  3. C
    Apply soft wrist restraints while the client is sleeping to prevent unassisted ambulation.
  4. D
    Delegate the completion of the initial fall risk assessment to assistive personnel.
  5. Leave a nightlight on in the client's room and bathroom during the night.Answer

Answer

The correct interventions are placing the bed in the lowest position with locked wheels, keeping the call light and personal items within easy reach, and leaving a nightlight on during the night.
The correct interventions focus on environmental modifications that directly address the client's visual impairment and weakness. Keeping the bed low, items within reach, and maintaining a nightlight all reduce the need for unassisted movement and improve visibility, significantly lowering the risk of falls without restricting the client.

Step-by-Step Solution

1
Analyze the client's risk factors.
The client has bilateral cataracts (visual impairment) and generalized weakness, placing them at high risk for falls.
Understanding the specific deficits helps tailor the safety interventions.
2
Evaluate each intervention for safety and appropriateness.
Environmental modifications like low beds, accessible items, and nightlights directly address the client's visual and mobility deficits.
Effective fall prevention relies on modifying the environment to support the client's limitations.
3
Identify contraindicated or out-of-scope actions.
Applying restraints as a first resort and delegating initial assessments to assistive personnel are inappropriate and unsafe actions.
Nursing interventions must adhere to legal scopes of practice and the principle of using the least restrictive measures.

Key Concept

Basic environmental modifications and safe delegation are essential for fall and injury prevention in clients with visual and physical deficits.
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Topics

Accident, Error, and Injury Prevention

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