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Difficulty: MediumSafe Use of Restraints and Safety Devices

A charge nurse on a medical-surgical unit is evaluating a client with advanced Parkinson's disease who is experiencing acute confusion. The client repeatedly attempts to stand up and walk unassisted, demonstrating an unsteady gait and a high risk for falls. What is the most appropriate initial intervention by the nurse?

  1. A
    Activate the bed alarm and instruct the unlicensed assistive personnel (UAP) to assess the client's cognitive status every hour.
  2. B
    Secure a vest restraint to the client and tie the straps securely to the movable side rails of the bed.
  3. Relocate the client to a room close to the nurses' station and provide a purposeful diversionary activity.Answer
  4. D
    Contact the healthcare provider to obtain an as-needed (PRN) order for soft wrist restraints in case the behavior worsens.

Answer

The most appropriate initial action is to relocate the client to a room close to the nurses' station and provide a purposeful diversionary activity.
The correct intervention prioritizes client safety by utilizing the least restrictive alternative first. Relocating the client closer to the nurses' station enhances visual monitoring, and providing a purposeful diversionary activity channels the client's restlessness safely without restricting their movement. This approach complies with national safety standards regarding restraint avoidance.

Step-by-Step Solution

1
Identify the primary safety risk and the clinical need for intervention.
The client is experiencing acute confusion, has an unsteady gait, and is exhibiting wandering behavior, which creates a high risk for falls and injury.
Recognizing the specific safety threat helps the nurse prioritize the most appropriate and least restrictive intervention.
2
Evaluate the appropriateness of restraint use based on regulatory guidelines.
Determine that physical restraints are interventions of last resort and must be preceded by documented non-pharmacological alternative measures.
Nursing standards mandate that less restrictive measures must be exhausted before applying any restraints to preserve client dignity and prevent restraint-related injuries.
3
Select the most appropriate least restrictive alternative.
Choose to relocate the client for closer visual observation and provide a safe, distracting activity (like folding washcloths).
These interventions directly address the restless behavior while maximizing client safety, maintaining mobility, and adhering to standard care protocols.

Key Concept

Implementation of least restrictive alternatives prior to restraint application
Estimated Time:1m 0s
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Topics

Safe Use of Restraints and Safety Devices

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