Examkin

Question

Difficulty: Very hardAccident, Error, and Injury Prevention

A nurse is developing a safety care plan for an older adult client with advanced dementia who is at a high risk for falls. To strictly adhere to the ethical and legal principle of utilizing the least restrictive environment, arrange the following fall prevention interventions in order of implementation, from the LEAST restrictive (baseline measure) to the MOST restrictive (last resort).

  1. 1Implement universal safety measures by keeping the bed in the lowest position and locking the wheels.
  2. 2Apply specific visual identifiers, such as a color-coded fall-risk wristband and non-slip footwear.
  3. 3Activate a weight-sensitive bed and chair alarm system to alert staff of unassisted movement.
  4. 4Relocate the client to a room directly adjacent to the nursing station for increased visual surveillance.
  5. 5Obtain a prescription for a continuous 1:1 dedicated safety sitter to remain constantly at the bedside.

Answer

The interventions must be sequenced progressively from universal, non-restrictive baseline precautions up to continuous, highly restrictive human observation.
The sequence correctly applies the ethical and legal principle of the least restrictive environment to fall prevention. The nurse must start with universal baseline precautions, progress to non-restrictive visual identifiers, introduce technological monitoring when risk increases, escalate to environmental surveillance (room relocation) if alarms are insufficient, and finally resort to constant human observation only when all lesser interventions fail to ensure safety.

Step-by-Step Solution

1
Identify the absolute baseline environmental precaution.
Implement universal safety measures (low bed, locked wheels).
This is a non-restrictive foundational safety standard that must be applied to every single client, representing the lowest possible level of intervention.
2
Identify the next least restrictive targeted intervention.
Apply visual identifiers and non-slip footwear.
This identifies the risk and provides basic physical protection (traction) without altering the client's environment or actively monitoring them.
3
Determine the first level of active surveillance.
Activate weight-sensitive bed and chair alarms.
Technological monitoring restricts the client's psychological freedom to move unobserved but allows them to remain in their original environment.
4
Determine the next level of environmental restriction.
Relocate the client to a room adjacent to the nursing station.
Changing the client's physical housing specifically to enforce high-frequency visual surveillance is a highly restrictive environmental modification.
5
Identify the most restrictive non-physical intervention.
Assign a continuous 1:1 dedicated safety sitter.
Constant human observation completely removes privacy and is highly resource-intensive; it is the final step before physical restraints are considered.

Key Concept

Escalation of fall prevention strategies based on the principle of the least restrictive environment.
Estimated Time:1m 30s
Rate this question

Topics

Accident, Error, and Injury Prevention

More questions from this topic