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Question

Difficulty: EasyUse of Restraints and Safety Devices

During the night shift, a client with a urinary tract infection becomes highly agitated and repeatedly tries to swing their legs over the bed rails. Which initial action should the practical nurse take to maintain client safety?

  1. Relocate the client's bed to a room that is highly visible from the nursing stationAnswer
  2. B
    Ask the healthcare provider for an immediate order for bilateral soft wrist restraints
  3. C
    Instruct the assistive personnel to administer a prescribed as-needed anti-anxiety medication
  4. D
    Note the agitation in the client's chart as a normal age-related cognitive change

Answer

Relocate the client's bed to a room that is highly visible from the nursing station
Moving the client to a room highly visible from the nursing station is a safe, non-invasive alternative that allows for closer monitoring. Nurses must always attempt least restrictive measures before resorting to physical or chemical restraints.

Step-by-Step Solution

1
Assess the client's immediate safety needs and the cause of the agitation.
The client is restless and at risk for a fall, requiring prompt intervention.
Ensuring safety is the primary nursing priority for an agitated client.
2
Determine the least restrictive intervention available.
Moving the client closer to the nursing station provides continuous observation.
Restraints (both physical and chemical) are only used after all other alternative safety measures have failed.

Key Concept

Prioritizing least restrictive alternatives before utilizing physical or chemical restraints
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Topics

Use of Restraints and Safety Devices

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