Examkin

Soru

Zorluk: OrtaAccident, Error, and Injury Prevention

A client is admitted to the neurology unit following a traumatic brain injury. The client is experiencing acute delirium, is highly disoriented, and repeatedly attempts to climb over the bed rails, creating a significant fall hazard. To ensure the client's safety and prevent injury, which intervention should the nurse implement first?

  1. Arrange for a dedicated staff member to remain in the room for continuous observation and verbal de-escalation.Cevap
  2. B
    Leave the client's room briefly to gather padded side rail covers and request assistance from the charge nurse.
  3. C
    Assign a nursing assistant to conduct hourly assessments of the client's cognitive function and orientation.
  4. D
    Contact the primary healthcare provider to secure an emergency order for bilateral wrist restraints.

Cevap

The correct action is to arrange for a dedicated staff member to remain in the room for continuous observation and verbal de-escalation.
For a highly disoriented and agitated client at severe risk for falls, maintaining continuous one-to-one observation is the most effective and least restrictive immediate intervention. It ensures immediate physical safety while allowing for verbal de-escalation and reorientation without resorting to physical or chemical restraints.

Adım Adım Çözüm

1
Identify the immediate safety threat.
The client is actively attempting to climb out of bed, posing a severe and imminent fall risk.
Recognizing imminent danger dictates that the nurse cannot leave the unsafe environment.
2
Evaluate potential interventions based on the principle of least restrictive environment.
Physical restraints are a last resort; a dedicated sitter is a less restrictive alternative.
Safety protocols require attempting and exhausting non-restraint alternatives before applying restraints.
3
Determine the appropriate delegation of tasks.
A staff member can observe the client, but only a registered nurse can assess cognitive status.
Maintaining the RN scope of practice ensures safe, legal care delivery and accurate clinical judgments.
4
Select the highest priority immediate action.
Providing continuous one-to-one observation addresses the immediate physical threat without violating delegation or restraint protocols.
Direct observation ensures immediate physical intervention if the client attempts to exit the bed.

Anahtar Kavram

Applying least restrictive alternatives and prioritizing immediate physical safety in clients with acute delirium.
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Konular

Accident, Error, and Injury Prevention

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