Examkin

Soru

Zorluk: OrtaAccident, Error, and Injury Prevention

An older adult client admitted with a severe respiratory infection suddenly becomes highly agitated, disoriented, and repeatedly attempts to climb over the side rails of the bed. Which of the following immediate actions should the practical nurse (PN) take to prevent injury? (Select all that apply)

  1. Move the client to a room located closer to the nurses' station for increased visibility.Cevap
  2. B
    Apply soft limb restraints to prevent the client from exiting the bed independently.
  3. Instruct an unlicensed assistive personnel (UAP) to remain at the bedside for continuous direct observation.Cevap
  4. D
    Reassure the family that the sudden onset of disorientation is an expected part of the aging process.
  5. Activate a bed exit alarm to alert staff when the client attempts to stand up.Cevap
  6. F
    Direct the UAP to perform a comprehensive neurological assessment to determine the cause of the agitation.

Cevap

The correct actions include moving the client closer to the nurses' station, assigning a UAP for continuous bedside observation, and activating a bed exit alarm.
Ensuring client safety requires implementing the least restrictive interventions first. Moving the client closer to the nurses' station, assigning a dedicated sitter (UAP), and using bed alarms all provide increased monitoring and fall prevention without unnecessarily restricting the client's physical movement. These actions fall appropriately within the PN scope of practice and delegation rules.

Adım Adım Çözüm

1
Identify the primary clinical problem and risk.
The client is experiencing acute confusion (delirium) and is at an immediate, high risk for falls and physical injury due to attempts to climb out of bed.
Recognizing the immediate safety threat dictates the urgency and type of interventions required.
2
Select interventions that prioritize safety using the least restrictive means possible.
Selected moving the client closer for observation, assigning a sitter, and using bed alarms.
Nursing standards mandate that non-restrictive safety measures must be implemented and evaluated before any form of physical restraint is considered.
3
Evaluate the incorrect interventions based on scope of practice and clinical principles.
Eliminated applying restraints, delegating assessments to the UAP, and dismissing the confusion as normal aging.
Restraints are a last resort, UAPs cannot perform clinical assessments, and acute confusion indicates an underlying medical issue (delirium) requiring treatment, not a normal aging change.

Anahtar Kavram

Implementing least restrictive safety measures and appropriate delegation for clients experiencing acute delirium.
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Konular

Accident, Error, and Injury Prevention

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