Examkin

Question

Difficulty: MediumLegal Rights and Responsibilities

An older adult client with a history of vascular dementia is hospitalized for the treatment of a severe urinary tract infection. The client becomes highly agitated, frequently picking at their peripheral intravenous (IV) catheter, and attempting to climb out of bed unassisted. The client's legally appointed healthcare proxy is currently sitting at the bedside. Which initial nursing action is most legally sound to protect the client's right to a least restrictive environment?

  1. A
    Contact the healthcare provider to obtain an immediate prescription for bilateral soft wrist restraints.
  2. B
    Delegate the task of physically holding the client's wrists away from the IV site to the unlicensed assistive personnel.
  3. C
    Inform the healthcare proxy that the sudden increase in agitation is a normal physiological part of the aging process.
  4. Cover the IV insertion site with a protective sleeve and encourage the healthcare proxy to help redirect the client's attention.Answer

Answer

Cover the IV insertion site with a protective sleeve and encourage the healthcare proxy to help redirect the client's attention.
Upholding a client's legal right to the least restrictive environment requires the nurse to exhaust and document all alternative safety measures before applying physical restraints. Covering the IV site and utilizing the family's presence for distraction are appropriate, non-restrictive first steps that protect both the client's safety and their legal rights.

Step-by-Step Solution

1
Identify the legal and ethical principle at stake in the scenario.
The scenario tests the client's legal right to be treated in the least restrictive environment possible.
Nurses are legally mandated to prevent false imprisonment and avoid unnecessary physical or chemical restraints.
2
Evaluate the proposed interventions against the principle of least restrictive environment.
Applying soft restraints or having staff physically hold the client down are restrictive measures. Covering the line and using family for distraction are non-restrictive.
Alternative, less restrictive measures must always be attempted and documented before restraints are considered to protect the client's rights.
3
Select the action that provides safety while upholding the client's legal rights.
Covering the IV site and utilizing the healthcare proxy for distraction is chosen as the correct first step.
This approach addresses the clinical need to protect the IV access without violating the client's legal rights to freedom from unnecessary restraint.

Key Concept

Client's Right to the Least Restrictive Environment
Rate this question

Topics

Legal Rights and Responsibilities

More questions from this topic