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Question

Difficulty: MediumSafe Use of Restraints and Safety Devices

A registered nurse (RN) is planning care for an older adult client with severe dementia who is agitated and repeatedly attempting to remove a newly placed enteral feeding tube. Which action regarding the use of safety devices or restraints is most appropriate for the RN to implement?

  1. Attempt to conceal the feeding tube under the client's gown and provide a therapeutic sensory activity apron.Answer
  2. B
    Apply physical restraints immediately because protecting the medical device takes priority over trialing alternative measures.
  3. C
    Delegate the continuous monitoring of the client's neurovascular status and skin integrity to the unlicensed assistive personnel (UAP).
  4. D
    Assume the severe agitation is an expected part of the aging process and request an as-needed (PRN) restraint prescription.

Answer

The most appropriate action is to attempt to conceal the feeding tube under the client's gown and provide a therapeutic sensory activity apron.
Concealing the medical device and providing a distraction, such as a sensory activity apron, represent effective, less restrictive alternative measures. The standard of care requires nurses to exhaust and properly document non-pharmacological, less restrictive alternatives before considering any form of physical or chemical restraint. This protects client autonomy and reduces the risks associated with immobility.

Step-by-Step Solution

1
Assess the client's behavior and the risk to the medical device (enteral feeding tube).
The client is agitated and attempting to pull the tube, posing a safety risk.
Understanding the specific behavior helps tailor the intervention.
2
Determine the least restrictive intervention that ensures patient safety.
Identify non-restraint alternatives such as camouflage (concealing the tube) and distraction (sensory apron).
Regulatory and nursing standards require exhausting and documenting less restrictive measures before utilizing restraints.
3
Implement the non-pharmacological and non-physical restraint alternatives.
The tube is concealed and the client is given a safe item to manipulate with their hands.
This directly addresses the pulling behavior while preserving the client's autonomy and physical freedom.

Key Concept

Prioritizing least restrictive alternatives before restraint application
Estimated Time:1m 15s
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Topics

Safe Use of Restraints and Safety Devices

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