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Question

Difficulty: MediumAccident, Error, and Injury Prevention

A charge nurse is conducting environmental safety rounds on a medical-surgical unit. Which observation involving a client with severe cognitive impairment and a high risk for falls requires immediate intervention to prevent injury?

  1. All four side rails on the client's bed are elevated while the client is resting unsupervised.Answer
  2. B
    A pressure-sensitive bed exit alarm is placed beneath the client's mattress.
  3. C
    An unlicensed assistive personnel (UAP) is stationed in the room to engage the client in folding towels.
  4. D
    The client is assigned to a room that is directly visible from the main nurses' station.

Answer

The observation requiring immediate intervention is the elevation of all four side rails on the client's bed.
The correct answer highlights an unsafe practice. Elevating all four side rails on a bed without a specific medical indication (such as seizure precautions) constitutes a physical restraint. For a client with severe cognitive impairment who is prone to wandering, this creates a high risk of injury. The client may attempt to climb over the rails, which increases the fall height and the severity of potential trauma, or they may become entrapped between the rails.

Step-by-Step Solution

1
Evaluate each observation to determine if it represents a safety hazard or an appropriate injury prevention strategy.
Three options represent appropriate safety interventions, while one represents a physical restraint.
Identifying the unsafe practice is necessary to determine which action requires immediate intervention by the charge nurse.
2
Analyze the impact of elevating all four side rails on a cognitively impaired client.
It is identified as a physical restraint that increases the risk of entrapment or a severe fall if the client attempts to climb over them.
Cognitively impaired clients may not understand the purpose of the rails and can sustain worse injuries attempting to bypass them.

Key Concept

Accident, Error, and Injury Prevention: Restraint Alternatives and Fall Precautions
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Topics

Accident, Error, and Injury Prevention

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