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Difficulty: MediumSafe Use of Restraints and Safety Devices

A nurse is caring for an older adult client who was recently admitted with bacterial pneumonia and has suddenly developed acute delirium. The client is highly restless, disoriented to place, and repeatedly attempts to climb over the bed rails. The client's visiting family member expresses intense concern and insists that physical restraints be applied immediately to prevent a fall. Which action should the nurse take first?

  1. A
    Contact the primary healthcare provider immediately to request a prescription for physical bed restraints.
  2. B
    Explain to the family that a sudden onset of confusion and restlessness are expected, normal changes in older adults during hospitalization.
  3. Move the client to a room closer to the nurses' station and implement a bed exit alarm system.Answer
  4. D
    Direct the unlicensed assistive personnel (UAP) to independently assess the client's level of agitation to determine if a bedside sitter is necessary.

Answer

The nurse should first move the client to a room closer to the nurses' station and implement a bed exit alarm system.
The correct answer demonstrates the fundamental nursing principle of using the least restrictive environment to maintain client safety. Moving the client closer to the nurses' station allows for frequent observation, and a bed alarm provides an immediate alert if the client attempts to get up. Both are appropriate first-line interventions for a confused, high-risk client.

Step-by-Step Solution

1
Assess the client's behavior and the immediate risk to their safety.
The client is experiencing acute delirium, restlessness, and is at high risk for falls.
Accurate assessment identifies the specific safety hazards that need to be addressed before selecting an intervention.
2
Evaluate the family's request for physical restraints against legal and ethical nursing standards.
Physical restraints are determined to be a measure of last resort, not a first-line intervention.
Nurses are legally required to attempt and document less restrictive alternatives before applying physical restraints to any client.
3
Implement the least restrictive alternative interventions available on the unit.
The client is moved closer to the nurses' station and a bed alarm is applied.
These measures promote client safety, allow for rapid staff response, and maintain the client's freedom of movement and dignity.

Key Concept

Prioritizing least restrictive safety alternatives before applying physical restraints
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Topics

Safe Use of Restraints and Safety Devices

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