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Difficulty: HardAccident, Error, and Injury Prevention

A nurse and an unlicensed assistive personnel (UAP) are in the room of a client experiencing severe alcohol withdrawal syndrome. The client suddenly becomes highly agitated, reports seeing insects on the walls, and actively attempts to climb over the bed rails. Which instruction should the nurse give the UAP to best ensure immediate client safety?

  1. A
    Raise all four side rails to secure the client in the bed before exiting the room to notify the healthcare provider
  2. B
    Evaluate the client's neurological status and determine what is triggering the hallucinations while the nurse prepares the medication
  3. Remain at the bedside to provide continuous observation and speak calmly to the client while the nurse obtains the prescribed medicationAnswer
  4. D
    Step out of the room quickly to gather soft wrist restraints from the supply closet to prevent the client from pulling at equipment

Answer

The instruction to remain at the bedside to provide continuous observation and speak calmly to the client while the nurse obtains the prescribed medication is the safest intervention.
The immediate priority for a highly agitated, hallucinating client attempting to climb out of bed is direct observation to prevent a fall. Having the UAP act as a sitter is a safe, least-restrictive alternative that protects the client from injury while the RN obtains necessary pharmacological interventions.

Step-by-Step Solution

1
Analyze the immediate threat to the client.
The client is actively attempting to climb out of bed while hallucinating, presenting an imminent fall and injury risk.
Identifying the highest priority risk dictates the urgency and type of the required intervention.
2
Evaluate the available resources and scope of practice.
A UAP is present. The UAP cannot assess the client or initiate physical restraints, but they can provide basic safety observation.
Delegating appropriately ensures interventions are legal, safe, and effective without violating the nurse practice act.
3
Select the least restrictive, most effective safety measure.
Assigning the UAP to stay at the bedside provides a 1:1 observation alternative to restraints, protecting the client from falling while the RN retrieves necessary medication to treat the underlying withdrawal.
Restraint alternatives must be exhausted first, and a client at high risk of falling must never be left completely unattended.

Key Concept

Accident, Error, and Injury Prevention: Restraint Alternatives and Delegation
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Topics

Accident, Error, and Injury Prevention

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