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Difficulty: EasyAccident, Error, and Injury Prevention

A nurse is admitting an older adult client who has a history of falls and occasionally experiences acute confusion. Which of the following is the most appropriate initial nursing action to promote safety and prevent injury?

  1. Keep the client's bed in the lowest position and place the call light within easy reach.Answer
  2. B
    Apply soft wrist restraints to prevent the client from getting up unassisted.
  3. C
    Delegate the initial fall risk assessment to the unlicensed assistive personnel (UAP).
  4. D
    Explain to the family that sudden confusion and falling are normal physiological parts of the aging process.

Answer

Keep the client's bed in the lowest position and place the call light within easy reach.
Keeping the bed in the lowest position and ensuring the call light is immediately accessible are standard, universal fall precautions. These non-restrictive interventions empower the client to call for help while minimizing the physical distance to the floor should a fall occur, thereby directly reducing the risk of severe injury.

Step-by-Step Solution

1
Identify the client's specific safety risk factors based on the clinical presentation.
The client has a history of falls and experiences acute confusion, placing them at high risk for subsequent falls and injuries.
Recognizing risk factors dictates the prioritization of preventative safety interventions.
2
Determine the most appropriate, least restrictive initial safety measure.
Implementing universal fall precautions, such as keeping the bed low and the call bell accessible, is chosen.
Nursing standards mandate using the least restrictive interventions first to promote safety while maintaining the client's autonomy and dignity.

Key Concept

Universal Fall Precautions and Least Restrictive Interventions
Estimated Time:1m 0s
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Topics

Accident, Error, and Injury Prevention

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