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Difficulty: MediumAccident, Error, and Injury Prevention

A registered nurse is developing a safety care plan for a client admitted with acute alcohol withdrawal who is experiencing severe agitation and is at high risk for seizures. Which of the following interventions should the nurse include to prevent injury? Select all that apply.

  1. Pad the client's side rails and ensure the bed is in the lowest locked position.Answer
  2. Verify that functioning suction equipment and supplemental oxygen are at the bedside.Answer
  3. Assign the client to a room near the nurses' station to facilitate close observation.Answer
  4. D
    Apply bilateral soft wrist restraints to prevent the client from dislodging their intravenous (IV) catheter.
  5. E
    Delegate the initial assessment of the client's fall risk to the unlicensed assistive personnel (UAP).
  6. F
    Place the client in a supine position during an active seizure to maintain spinal alignment.

Answer

The correct interventions are: padding the side rails and keeping the bed in the lowest position, ensuring suction and oxygen are at the bedside, and assigning the client to a room near the nurses' station.
For a client experiencing acute alcohol withdrawal with severe agitation and high seizure risk, maintaining a safe environment is the top priority. Essential seizure precautions include padding the side rails, keeping the bed in the lowest locked position, and having functioning suction and oxygen equipment immediately accessible at the bedside to manage potential airway compromise. Additionally, placing the client in a room near the nurses' station is a vital non-pharmacological safety measure that allows for continuous monitoring and rapid intervention without resorting to restraints.

Step-by-Step Solution

1
Identify the primary safety risks for a client in acute alcohol withdrawal.
The client is highly agitated and at significant risk for tonic-clonic seizures, falls, and self-injury.
Understanding the specific risks dictates the appropriate preventive interventions that must be prioritized in the care plan.
2
Select interventions that address seizure safety and fall prevention.
Padding the side rails, keeping the bed low and locked, and ensuring airway equipment (suction and oxygen) is ready are standard, essential seizure precautions.
These measures protect the client from physical trauma and prepare the nurse to manage airway compromise effectively if a seizure occurs.
3
Evaluate interventions regarding monitoring and restraint use.
Placing the client near the nurses' station allows for frequent monitoring. Restraints should be avoided as a first-line measure.
Less restrictive alternatives, such as close observation, must always be prioritized over physical restraints to maintain safety and comply with strict facility and legal regulations.
4
Evaluate the delegation and positioning options.
Do not delegate initial assessments to UAP, and do not place a seizing client in a supine position.
Assessments require the registered nurse's clinical judgment. The side-lying position is absolutely required during a seizure to prevent aspiration.

Key Concept

Accident, Error, and Injury Prevention in the High-Risk Client
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Topics

Accident, Error, and Injury Prevention

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