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Difficulty: Very hardAccident, Error, and Injury Prevention

A practical nurse (PN) is providing care for an older adult client recently admitted with suspected urosepsis. The client has a documented history of moderate Alzheimer's disease. During the shift, the client becomes acutely agitated, begins shouting, and repeatedly attempts to remove a newly inserted peripheral intravenous (IV) catheter. An unlicensed assistive personnel (UAP) suggests using soft wrist restraints, noting that the client is becoming a danger to themselves. Which initial action must the PN prioritize to ensure client safety?

  1. Conceal the IV site with a loose tubular bandage, evaluate the client for physiological stressors such as hypoxia or a full bladder, and initiate constant observation.Answer
  2. B
    Attribute the behavioral changes to the client's underlying Alzheimer's disease and administer a prescribed PRN sedative to prevent self-injury.
  3. C
    Contact the healthcare provider to obtain a client-specific prescription for bilateral soft wrist restraints, as standing facility protocols are invalid for restraint use.
  4. D
    Attempt to logically explain the medical necessity of the IV catheter to the client, while physically blocking their hands from reaching the insertion site.

Answer

The priority action is to conceal the IV site with a loose tubular bandage, evaluate for physiological stressors, and initiate constant observation.
The correct answer prioritizes the legal and ethical mandate to exhaust all less restrictive alternatives before applying physical or chemical restraints. Concealing the medical device reduces the visual stimulation that triggers pulling, while assessing for physiological stressors (such as hypoxia or a full bladder) addresses the root cause of acute delirium commonly seen with urosepsis. Constant observation ensures immediate safety without restricting the client's movement.

Step-by-Step Solution

1
Assess the legal and ethical requirements for restraint application.
The nurse identifies that regulatory guidelines strictly mandate the exhaustion and documentation of all less restrictive alternatives before any restraints can be applied.
Restraints are a treatment of last resort, not a first-line intervention for agitation.
2
Differentiate between the client's chronic dementia and acute delirium.
The nurse recognizes that sudden, acute agitation in a client with an infection (urosepsis) strongly indicates delirium caused by a physiological stressor, rather than a normal progression of Alzheimer's disease.
Treating the underlying physiological cause (e.g., hypoxia, urinary retention, pain) often resolves the behavioral crisis without the need for mechanical restrictions.
3
Implement the least restrictive safety measures immediately.
The nurse conceals the medical device to remove the visual trigger, assesses vital signs/physiological needs, and ensures continuous 1:1 observation.
These actions prioritize immediate client safety, protect the medical equipment, and strictly adhere to the legal mandate of injury prevention without utilizing physical or chemical restraints.

Key Concept

Restraint Alternatives and Delirium Management
Estimated Time:2m 0s
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Topics

Accident, Error, and Injury Prevention

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