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Difficulty: MediumAccident, Error, and Injury Prevention

While conducting midnight rounds on a medical-surgical unit, a nurse discovers an older adult client who is acutely confused, highly restless, and attempting to climb out of bed. The client was alert and oriented during the previous shift. Which action should the nurse implement first to ensure the client's safety?

  1. Relocate the client to a room near the nurses' station and activate a bed exit alarm.Answer
  2. B
    Raise all four side rails on the client's bed to create a physical barrier against falls.
  3. C
    Delegate the assessment of the client's neurological status to an unlicensed assistive personnel.
  4. D
    Document the confusion as a normal age-related change and dim the room lights to encourage rest.

Answer

The nurse should relocate the client to a room near the nurses' station and activate a bed exit alarm.
Moving the client to a room near the nurses' station and utilizing a bed alarm are appropriate, non-restrictive interventions. These actions prioritize client safety through enhanced surveillance and early intervention, adhering directly to the standard of using the least restrictive alternative to prevent injury.

Step-by-Step Solution

1
Analyze the client's clinical presentation.
The client is experiencing an acute onset of confusion (delirium) and restlessness, which creates an immediate risk for falls and traumatic injury.
Identifying the urgency of the safety hazard determines the necessary level of intervention.
2
Evaluate the proposed interventions against the principle of least restrictive alternatives.
Relocating the client and using a bed alarm are non-restrictive safety measures. Using four side rails is a physical restraint, and ignoring the symptom is clinically unsafe.
Ethical standards and healthcare regulations mandate that nurses exhaust all less restrictive environmental modifications before utilizing physical or chemical restraints.

Key Concept

Restraint Alternatives and Injury Prevention
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Topics

Accident, Error, and Injury Prevention

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