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Question

Difficulty: MediumAccident, Error, and Injury Prevention

A client on a rehabilitation unit is recovering from a stroke and suddenly becomes highly agitated, repeatedly attempting to stand and walk unassisted. To prevent a fall and maintain environmental safety, which action is the priority for the practical nurse (PN) to implement?

  1. Relocate the client to a room immediately adjacent to the nurses' station to ensure continuous visual observation.Answer
  2. B
    Fasten a specialized torso vest to the bed frame to safely restrict the client's unassisted mobility.
  3. C
    Document the sudden agitation as an expected, age-related cognitive decline and continue routine care.
  4. D
    Delegate the task of evaluating the client's neurological status to the assigned assistive personnel (AP).

Answer

Relocate the client to a room immediately adjacent to the nurses' station to ensure continuous visual observation.
The standard of care for injury prevention mandates using the least restrictive intervention first. Relocating the client closer to the nurses' station modifies the environment to allow for frequent, direct observation. This promotes safety and allows staff to redirect the client quickly before a fall occurs, entirely avoiding the use of physical restraints.

Step-by-Step Solution

1
Analyze the client's current behavior.
The client is exhibiting sudden agitation and making unassisted attempts to stand.
Recognizing these behaviors identifies a high and immediate risk for falls and physical injury.
2
Identify the need for a prompt safety intervention.
The intervention must align with the principle of using the least restrictive means possible.
Nursing standards require exhausting less restrictive safety measures before utilizing physical or chemical restraints.
3
Select the optimal environmental modification.
Moving the client to a highly visible room is identified as the priority action.
This allows for continuous monitoring by staff, enabling rapid intervention before a fall occurs without compromising the client's physical freedom.
4
Rule out unsafe or out-of-scope actions.
Physical restraints and delegating assessments to assistive personnel are rejected.
Restraints require a provider's order and are a last resort, while nursing assessments cannot be legally delegated to unlicensed staff.

Key Concept

Implementing least restrictive environmental modifications for client safety and injury prevention.
Estimated Time:1m 15s
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Topics

Accident, Error, and Injury Prevention

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