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Zorluk: KolayUse of Restraints and Safety Devices

An older adult client who was recently admitted is exhibiting sudden restlessness and frequently trying to climb over the side rails to get out of bed unassisted. Which of the following initial interventions should the practical nurse (PN) implement as non-restrictive safety measures? Select all that apply.

  1. Place the client in a room closer to the nurses' station for enhanced observation.Cevap
  2. Provide familiar items from the client's home, such as a favorite blanket.Cevap
  3. C
    Apply soft wrist restraints loosely to prevent the client from leaving the bed.
  4. D
    Document the sudden restlessness as a normal, age-related cognitive decline.

Cevap

The correct interventions are placing the client in a room closer to the nurses' station and providing familiar items from the client's home.
Relocating the client to a room near the nurses' station ensures frequent monitoring, while providing familiar objects can help reorient and comfort them. Both of these are highly effective, non-restrictive strategies that prioritize safety while maintaining dignity.

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1
Identify the primary clinical problem
An older adult client is exhibiting sudden restlessness and is at high risk for falling by trying to climb out of bed.
Understanding the immediate safety risk is essential for selecting appropriate nursing interventions.
2
Determine the required safety approach
The nurse must use least restrictive alternatives before considering any form of physical or chemical restraint.
Standard safety and ethical guidelines mandate that non-restrictive measures be exhausted first to protect client autonomy and prevent restraint-related injuries.
3
Select the appropriate non-restrictive interventions
Enhanced observation by moving the client near the nurses' station and utilizing familiar objects for reorientation are chosen.
These actions directly address the safety risk and promote a calming environment without limiting the client's movement.

Anahtar Kavram

Prioritizing least restrictive alternatives for restless or confused clients
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Konular

Use of Restraints and Safety Devices

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