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Difficulty: EasyAccident, Error, and Injury Prevention

A clinical nurse is establishing an injury prevention plan for an older adult client who has diabetic peripheral neuropathy and severe visual impairment. Which of the following environmental and safety interventions should the nurse implement? Select all that apply.

  1. Ensure that the pathway from the bed to the bathroom is completely clear of clutter and loose equipment.Answer
  2. B
    Raise all four side rails on the client's bed to serve as a physical boundary against falling.
  3. Verify that the client is wearing properly fitted, non-skid footwear whenever out of bed.Answer
  4. D
    Ask the unlicensed assistive personnel to evaluate the client's risk for falls at the beginning of the shift.
  5. Place the call light, eyeglasses, and telephone within the client's immediate reach.Answer
  6. F
    Apply soft wrist restraints when the client is left alone in the room to prevent unsafe wandering.

Answer

The correct interventions are ensuring a clear pathway, verifying the use of non-skid footwear, and placing essential items within immediate reach.
Clients with peripheral neuropathy and visual impairment have compromised balance, sensation, and spatial awareness. Ensuring a clutter-free pathway, providing non-skid footwear, and keeping essential items within immediate reach proactively address these specific deficits and reduce the risk of accidental falls without using restrictive measures.

Step-by-Step Solution

1
Analyze the client's specific physical deficits.
The client has diabetic peripheral neuropathy (decreased sensation in feet) and severe visual impairment (decreased ability to see hazards).
Understanding the client's sensory deficits helps identify the most appropriate environmental modifications.
2
Evaluate the proposed safety interventions against nursing standards of practice.
Clearing pathways, using non-skid footwear, and keeping items in reach directly mitigate the client's specific risks without causing harm.
Evidence-based practice dictates using the least restrictive environment while directly addressing specific safety hazards.
3
Identify inappropriate or unsafe interventions.
Raising four side rails and applying wrist restraints are inappropriate use of restraints. Delegating a nursing assessment to UAP is outside their scope of practice.
Recognizing unsafe practices and improper delegation prevents further patient injury and professional liability.

Key Concept

Injury prevention strategies must prioritize less restrictive environmental modifications and adhere to the proper scope of practice for delegation.
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Topics

Accident, Error, and Injury Prevention

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