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Question

Difficulty: EasyAccident, Error, and Injury Prevention

A nurse is caring for a client who is confused, restless, and continuously attempting to get out of bed without assistance. Which intervention should the nurse implement first to promote a safe environment?

  1. A
    Apply soft wrist restraints to the client to immediately prevent falls.
  2. B
    Delay securing this client's environment to answer a call light for a stable client requesting water.
  3. Activate a bed exit alarm and maintain the bed in the lowest possible position.Answer
  4. D
    Delegate the completion of the formal fall risk assessment scale to the nursing assistant.

Answer

Activate a bed exit alarm and maintain the bed in the lowest possible position.
The safest and most appropriate initial intervention is to use a bed exit alarm and keep the bed in the lowest position. This approach adheres to the nursing principle of utilizing the least restrictive means necessary to ensure client safety while immediately addressing the fall risk.

Step-by-Step Solution

1
Analyze the client's condition and identify the immediate safety risk.
The client is confused, restless, and attempting to get out of bed, presenting a high and immediate risk for a fall.
Identifying the primary risk is the first step in determining the appropriate nursing intervention.
2
Evaluate potential interventions based on the principle of the least restrictive environment.
A bed alarm and a lowered bed are non-restrictive measures that address the safety risk without limiting the client's freedom unnecessarily.
Nursing standards require exhausting all less restrictive alternatives before considering any form of physical restraint.
3
Select the safest, most immediate action.
Activating the bed alarm and lowering the bed is determined to be the priority action.
This intervention directly mitigates the fall risk while adhering to core safety and legal protocols.

Key Concept

Prioritizing least restrictive safety measures and immediate injury prevention for confused clients.
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Topics

Accident, Error, and Injury Prevention

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