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Question

Difficulty: MediumAccident, Error, and Injury Prevention

An older adult client is receiving treatment for bacterial pneumonia on a medical unit. During the night shift, the client becomes newly agitated, attempts to climb over the bed rails, and exhibits acute confusion. Which of the following is the priority action for the practical nurse to take to ensure the client's safety?

  1. Relocate the client to a room near the nursing station to allow for continuous observation.Answer
  2. B
    Apply soft extremity restraints to the client's wrists to prevent them from climbing out of bed.
  3. C
    Attribute the sudden agitation to normal age-related cognitive decline and leave the client to rest.
  4. D
    Administer an intravenous push sedative to quickly manage the client's agitated behavior.

Answer

The priority action is to relocate the client to a room near the nursing station to allow for continuous observation.
Moving the client to a room near the nursing station provides necessary supervision and is a non-invasive, least-restrictive alternative to restraints. This action prioritizes the client's immediate physical safety while respecting their autonomy and adhering to standard safety and error prevention protocols.

Step-by-Step Solution

1
Identify the immediate safety risk to the client.
The client is experiencing acute confusion and attempting to climb over bed rails, posing a high and immediate risk for falls and physical injury.
Recognizing the severity of the risk guides the urgency and type of safety intervention required.
2
Evaluate potential interventions based on the principle of least restrictive care.
Environmental modifications, such as increased supervision, are preferred over physical restraints or chemical restraints.
Restraints can increase agitation and pose significant physical and psychological risks, so alternatives must always be exhausted first.
3
Select the most appropriate action that falls within the practical nurse scope of practice.
Relocating the client for better visibility ensures safety without violating scope of practice or unnecessarily restricting the client's movement.
Continuous observation is a direct, safe, and effective nursing method to prevent injury in a confused and agitated client.

Key Concept

Least Restrictive Safety Interventions and Scope of Practice
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Topics

Accident, Error, and Injury Prevention

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