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Difficulty: MediumAccident, Error, and Injury Prevention

A client is admitted to the medical-surgical unit following a right-hemispheric stroke. The client exhibits severe left-sided neglect, impulsive behavior, and impaired judgment. Despite having dense left-sided hemiparesis, the client repeatedly attempts to stand up and walk unassisted. Which intervention is the most appropriate initial action to prevent injury?

  1. Relocate the client to a room near the nurses' station and activate a bed-exit alarm.Answer
  2. B
    Apply a soft vest restraint to securely keep the client seated or in bed.
  3. C
    Delegate the task of performing the initial fall risk assessment to the unlicensed assistive personnel (UAP).
  4. D
    Document the impulsive behavior as a normal, expected age-related cognitive change that requires no specific safety intervention.

Answer

The most appropriate initial action is to relocate the client to a room near the nurses' station and activate a bed-exit alarm.
Relocating the client near the nurses' station increases visual surveillance, and a bed-exit alarm provides an immediate auditory warning when the client attempts to stand. This combination is highly effective for impulsive clients and strictly adheres to the fundamental nursing principle of using the least restrictive alternative to prevent falls and injury.

Step-by-Step Solution

1
Analyze the client's clinical presentation and identify the primary safety risk.
The client has impulsivity, left-sided neglect, and hemiparesis, creating an extremely high risk for unassisted falls.
Right-hemispheric strokes frequently impair judgment and spatial-perceptual orientation, leading clients to overestimate their abilities.
2
Select an intervention based on the principle of least restrictive measures.
Implementing close observation and an electronic bed alarm provides safety without restricting the client's movement.
Nursing standards mandate that safety interventions must prioritize the least restrictive measures before any physical or chemical restraints are considered.

Key Concept

Accident and Injury Prevention: Least Restrictive Interventions
Estimated Time:1m 15s
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Topics

Accident, Error, and Injury Prevention

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