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Question

Difficulty: MediumAccident, Error, and Injury Prevention

A client with a documented history of mild cognitive impairment is hospitalized for the treatment of pneumonia. During the shift, the client becomes abruptly agitated, frequently attempts to climb out of bed, and pulls at the intravenous tubing. Which action should the practical nurse implement to ensure safety while minimizing the use of restrictive devices?

  1. A
    Attribute the sudden agitation to the client's pre-existing cognitive decline and dim the room lights.
  2. Request that an unlicensed assistive personnel remain continuously at the bedside to provide direct observation.Answer
  3. C
    Secure the client's wrists with bilateral soft restraints to prevent removal of the intravenous access.
  4. D
    Instruct an unlicensed assistive personnel to perform and document hourly neurological assessments.

Answer

The most appropriate action is to request that an unlicensed assistive personnel remain continuously at the bedside to provide direct observation.
Providing continuous 1:1 observation utilizing an unlicensed assistive personnel (UAP) is a highly effective, non-restrictive alternative to physical restraints. This intervention immediately protects the client from injury, addresses the safety hazard, and strictly adheres to the UAP's legal scope of practice.

Step-by-Step Solution

1
Identify the primary client safety risk presented in the scenario.
The client is at a high risk for falls and self-injury (such as pulling out intravenous lines) due to acute, sudden-onset agitation.
Abrupt changes in behavior compromise client safety and require immediate preventative nursing measures.
2
Evaluate the appropriateness of physical restraints for this client.
Physical restraints should be avoided until all less restrictive alternatives have been exhausted.
Restraints can increase agitation and carry significant physical and psychological risks; they are strictly regulated as a measure of last resort.
3
Determine the safest and most appropriate delegation of tasks to maintain observation.
Assigning an unlicensed assistive personnel to act as a 1:1 sitter provides continuous observation within their scope of practice, whereas assigning them to perform neurological assessments is legally out of scope.
Nurses must delegate tasks that directly match the competency and legal scope of the healthcare personnel.

Key Concept

Restraint Alternatives and Safe Delegation
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Topics

Accident, Error, and Injury Prevention

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