Examkin

Soru

Zorluk: ZorAccident, Error, and Injury Prevention

An 82-year-old resident in a skilled nursing facility is receiving treatment for a lower respiratory tract infection. During the night shift, the practical nurse observes the resident repeatedly attempting to climb out of bed, pulling forcefully at their nasal cannula, and exhibiting sudden, incomprehensible speech. The resident's baseline documentation indicates they are fully oriented and independent. Which intervention is the priority for the practical nurse to implement to prevent client injury?

  1. Relocate the resident to a room directly visible from the nurses' station and provide a safe, repetitive motor activity.Cevap
  2. B
    Elevate all four side rails on the bed to create a physical barrier and secure the oxygen tubing out of reach.
  3. C
    Dim the room lights, reduce ambient noise, and document the nocturnal agitation as a typical age-related cognitive change.
  4. D
    Direct the unlicensed assistive personnel to evaluate the resident's neurological status and identify the trigger for the agitation.

Cevap

Relocate the resident to a room directly visible from the nurses' station and provide a safe, repetitive motor activity.
Moving the resident closer to the nurses' station ensures constant observation, while providing a purposeful, repetitive activity redirects their restless energy. This approach prioritizes safety and injury prevention utilizing the least restrictive environment, which is the standard of care before any physical restraints are considered.

Adım Adım Çözüm

1
Analyze the clinical presentation.
The resident is experiencing a sudden, acute change in mental status and behavior (delirium) likely secondary to a respiratory infection, creating a high risk for falls and medical equipment dislodgement.
Identifying the acuity and nature of the risk is necessary to determine the appropriate level of intervention.
2
Evaluate the proposed interventions against safety guidelines and the scope of practice.
Restraints (like four side rails) are prohibited without trying alternatives. Delegation of assessment to UAP is out of scope. Ignoring the acute change is clinically unsafe.
Prioritization requires selecting actions that are safe, legal, and effective.
3
Select the least restrictive, most effective priority action.
Relocating the client for direct observation and providing a diversionary activity addresses the immediate safety threat without violating restraint protocols or scope of practice.
Least restrictive measures must always be the first-line approach in managing agitated clients to prevent injury.

Anahtar Kavram

Implementing least restrictive alternatives, such as close observation and diversionary activities, is the priority standard of care for preventing injury in clients experiencing acute delirium.
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Konular

Accident, Error, and Injury Prevention

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