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Question

Difficulty: EasyAccident, Error, and Injury Prevention

A nurse is planning care for an older adult client with moderate dementia who frequently wanders the unit during the night and repeatedly attempts to open the stairwell doors. Which action is the most appropriate initial intervention to prevent injury?

  1. A
    Apply a soft vest restraint to keep the client securely in bed during the night shift.
  2. Relocate the client to a room located closer to the nurses' station for more frequent observation.Answer
  3. C
    Obtain a prescription for a sedative medication to administer when the wandering behavior begins.
  4. D
    Explain to the client at the start of the shift that the doors are locked for their own safety.

Answer

Relocate the client to a room located closer to the nurses' station for more frequent observation.
The correct answer emphasizes modifying the environment to enhance safety while maintaining the client's freedom of movement. Placing a wandering, confused client near the nurses' station allows for direct, frequent visual monitoring. This is a standard, non-restrictive safety measure that should always be attempted before considering more restrictive options.

Step-by-Step Solution

1
Identify the primary safety risk presented in the clinical scenario.
The client has moderate dementia and is at high risk for elopement or injury from wandering into unsafe areas like stairwells.
Recognizing the specific hazard dictates the type of intervention needed.
2
Evaluate the proposed interventions against the principle of 'least restrictive environment'.
Physical restraints and chemical restraints (sedatives) are highly restrictive and carry their own risks. Verbal instructions are ineffective due to the client's cognitive deficit.
Nurses must always attempt and document less restrictive safety measures before utilizing physical or chemical restraints.
3
Select the intervention that provides safety without unnecessarily restricting the client's autonomy.
Moving the client near the nurses' station increases surveillance without using restraints.
This environmental modification is a standard first-line restraint alternative for confused, wandering clients.

Key Concept

Restraint Alternatives and Environmental Modifications
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Topics

Accident, Error, and Injury Prevention

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