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Difficulty: EasySafe Use of Restraints and Safety Devices

A nurse on a medical-surgical unit is caring for a client who is experiencing acute confusion. The client repeatedly attempts to climb out of bed without assistance, posing a high risk for falls. Which of the following is the most appropriate initial nursing intervention to ensure client safety?

  1. Move the client to a room closer to the nursing station for frequent observation.Answer
  2. B
    Raise all four side rails on the client's bed to prevent the client from exiting.
  3. C
    Apply bilateral soft wrist restraints to keep the client safely in bed.
  4. D
    Delegate the unlicensed assistive personnel (UAP) to assess the underlying cause of the client's confusion.

Answer

Move the client to a room closer to the nursing station for frequent observation.
Before utilizing any form of physical restraint, the nurse must first implement and document less restrictive safety measures. Relocating a confused client closer to the nursing station allows for frequent monitoring, decreases isolation, and effectively promotes safety without unnecessarily restricting the client's freedom of movement.

Step-by-Step Solution

1
Identify the primary clinical problem and immediate risk.
The client has acute confusion and is at a high risk for falls due to unassisted bed exits.
Establishing the specific risk helps prioritize which interventions are both safe and legally sound.
2
Recall the legal and ethical guidelines regarding the use of safety devices and restraints.
Nurses must always implement the least restrictive alternatives before utilizing physical or chemical restraints.
Using restraints prematurely violates client rights and standard of care policies.
3
Evaluate the given options to find the least restrictive initial action.
Moving the client closer to the nursing station provides safety through increased supervision without restricting mobility or improperly delegating assessment.
This action correctly aligns with the principle of least restrictive alternative.

Key Concept

Least Restrictive Alternatives for Client Safety
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Topics

Safe Use of Restraints and Safety Devices

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