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Difficulty: MediumAccident, Error, and Injury Prevention

A 72-year-old client in a medical-surgical unit, who is normally fully independent and oriented, is found stumbling in the hallway at night. The client is suddenly disoriented, slurring words, and forcefully trying to push through a locked fire exit. To ensure safety and prevent injury, which action should the practical nurse (PN) implement first?

  1. Assist the client into a nearby chair or wheelchair to prevent a fall, initiate continuous observation, and obtain vital signs.Answer
  2. B
    Document the behavior as expected age-related nocturnal confusion and gently redirect the client to their room.
  3. C
    Administer a prescribed PRN intravenous (IV) push sedative to rapidly calm the client and prevent elopement.
  4. D
    Transfer the client to bed and immediately apply bilateral soft wrist restraints to prevent further wandering.

Answer

Assist the client into a nearby chair or wheelchair to prevent a fall, initiate continuous observation, and obtain vital signs.
The immediate priority in an emergency involving an unsteady client is to secure their physical safety to prevent an accidental fall. Assisting the client into a chair addresses this immediate injury risk. Furthermore, sudden disorientation and slurred speech in a previously independent client strongly suggest an acute medical event (such as a stroke, hypoxia, or severe infection). The nurse must initiate close observation and gather baseline vital signs to help determine the root cause of the acute delirium.

Step-by-Step Solution

1
Recognize the immediate physical hazard to the client.
The client is unsteady (stumbling) and at high risk for an accidental fall.
Wandering with physical instability requires immediate stabilization (sitting the client down) to prevent traumatic injury.
2
Identify the sudden change in baseline condition.
The acute onset of disorientation and slurred speech indicates a potential medical emergency, not normal aging.
Acute delirium or neurological deficits require urgent assessment (vital signs) to identify reversible or life-threatening causes.
3
Determine the safest priority intervention within the PN scope of practice.
Securing the client's physical safety and performing a baseline physiological assessment.
Restraints are a last resort, and administering IV push medications exceeds the standard PN scope of practice.

Key Concept

Prioritizing immediate physical safety and recognizing acute physiological changes over improper delegation or premature restraint use.
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Topics

Accident, Error, and Injury Prevention

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