During the night shift, a client who sustained a moderate traumatic brain injury becomes profoundly disoriented. The client repeatedly attempts to leave the neurological step-down unit, claiming they need to 'go to work.' An unlicensed assistive personnel (UAP) asks the registered nurse (RN) to authorize a vest restraint for safety. Which legal and professional actions must the RN take? (Select all that apply)
- Perform a comprehensive assessment to determine if underlying factors such as pain or a full bladder are causing the agitationAnswer
- BRequest an as-needed (PRN) prescription for physical restraints from the healthcare provider to use if the wandering continues
- Transfer the client to a vacant bed immediately adjacent to the main nurses' station for closer monitoringAnswer
- DDelegate the application of bilateral soft wrist restraints to the UAP until a formal medical evaluation can be completed
- Initiate continuous, one-to-one direct observation by a dedicated staff member to ensure client safetyAnswer
Answer
The correct actions are to perform a comprehensive assessment for underlying causes of agitation, transfer the client closer to the nurses' station, and initiate continuous one-to-one observation.
Under legal and regulatory standards, clients have the right to be cared for in the least restrictive environment. Before considering any physical restriction, the registered nurse must assess for reversible causes of confusion (such as pain, hypoxia, or a full bladder) and implement all feasible less restrictive alternatives. Relocating the client closer to the nurses' station and providing one-to-one observation are legally sound, proactive safety measures that protect the client from harm while preserving their autonomy.
Step-by-Step Solution
Key Concept
Legal Rights and Responsibilities: Restraint Regulations and Least Restrictive Environment