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Question

Difficulty: EasyUse of Restraints and Safety Devices

A client with dementia is pacing the unit hallway and repeatedly attempting to enter other clients' rooms. Which intervention should the practical nurse implement first to promote safety?

  1. Redirect the client to a quiet area and provide a simple, familiar activity.Answer
  2. B
    Guide the client back to bed and raise all four side rails.
  3. C
    Request a prescription for an as-needed (PRN) sedative medication.
  4. D
    Apply a soft belt restraint while the client is seated in a bedside chair.

Answer

Redirect the client to a quiet area and provide a simple, familiar activity.
The standard of nursing care dictates that the least restrictive measures must be attempted before any physical or chemical restraints are utilized. Redirecting a pacing client and providing a simple, familiar diversionary activity (such as folding towels) promotes safety, reduces agitation, and preserves the client's freedom and dignity.

Step-by-Step Solution

1
Identify the client's immediate safety risk and behavioral presentation.
The client is pacing and entering other rooms due to dementia, creating a potential safety and privacy concern.
Understanding the behavior guides the selection of the most appropriate and least restrictive intervention.
2
Recall the nursing guidelines regarding the use of restraints and safety devices.
Guidelines require implementing and documenting least restrictive alternatives before using any physical or chemical restraints.
Restraints pose significant physical and psychological risks and are legally restricted to be a measure of last resort.
3
Evaluate the given options to identify the least restrictive alternative.
Redirecting the client and providing a diversionary activity is the only option that does not act as a physical or chemical restraint.
Raising four side rails, administering sedatives, and applying a belt are all forms of restraint and violate the principle of least restrictive care when used as an initial step.

Key Concept

Implementing least restrictive alternatives before utilizing physical or chemical restraints.
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Topics

Use of Restraints and Safety Devices

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