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Difficulty: MediumAccident, Error, and Injury Prevention

A practical nurse (PN) in a long-term care facility is caring for an older adult client who has a baseline of mild dementia. The client begins pacing the unit corridors incessantly, exhibits a sudden onset of severe restlessness, and repeatedly attempts to open secured exit doors. Which priority action should the PN take to prevent injury?

  1. Escort the client to a low-stimulation, supervised area and introduce a simple, distracting activity.Answer
  2. B
    Contact the healthcare provider to obtain a prescription for physical restraints to prevent elopement.
  3. C
    Document the sudden increase in restlessness as an expected behavioral change associated with the client's dementia.
  4. D
    Direct the unlicensed assistive personnel (UAP) to assess the client for underlying causes of the agitation.

Answer

Escort the client to a low-stimulation, supervised area and introduce a simple, distracting activity.
The correct action prioritizes the client's immediate safety by moving them away from the hazardous exit doors and reducing environmental stimuli that may be contributing to the agitation. Engaging the client in a simple, supervised activity serves as a safe, non-restrictive intervention to manage the wandering behavior. This strictly adheres to the nursing principle of utilizing the least restrictive alternative first before considering more extreme measures.

Step-by-Step Solution

1
Identify the immediate safety risk.
The client is at risk for elopement and potential injury due to sudden severe restlessness and attempting to exit.
Recognizing the primary hazard dictates the urgency and type of intervention required.
2
Determine the most appropriate initial intervention based on safety guidelines.
A non-pharmacological, least restrictive alternative must be implemented first.
Standards of care require starting with the least restrictive measures to maintain client safety and dignity.
3
Select the action that addresses the risk while adhering to the principle of least restriction.
Redirecting the client to a safe, supervised environment with a distraction fulfills both requirements.
This approach mitigates the elopement risk without resorting to unauthorized or overly restrictive measures.

Key Concept

Implementing Least Restrictive Alternatives for Client Safety
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Topics

Accident, Error, and Injury Prevention

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