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Zorluk: OrtaAccident, Error, and Injury Prevention

During the night shift, a nurse responds to a bed alarm and finds an older adult client who has abruptly become disoriented. The client is restless, attempting to climb over the bed rails, and pulling forcefully at their indwelling urinary catheter. Which action should the nurse take first to protect the client from injury?

  1. A
    Request a provider prescription to secure the client's hands using protective holding devices.
  2. B
    Reassure the client's family that this acute disorientation is a normal, expected physiological consequence of the aging process.
  3. Stay at the bedside to verbally redirect the client while assessing for physiological triggers of the abrupt cognitive change.Cevap
  4. D
    Instruct an unlicensed assistive personnel (UAP) to evaluate the client's neurological status and determine the level of orientation.

Cevap

The most appropriate initial action is to remain at the bedside to redirect the client verbally and assess for underlying physiological causes of the sudden confusion.
The initial priority when managing a client with sudden delirium and agitation is to ensure immediate physical safety while identifying the underlying cause. Staying with the client allows the nurse to prevent injury, provide non-pharmacological redirection, and conduct a clinical assessment to rule out physiological triggers such as hypoxia, infection, or medication toxicity.

Adım Adım Çözüm

1
Identify the primary safety threat in the clinical scenario.
The client is experiencing sudden confusion, agitation, and an immediate risk of injury from climbing out of bed or pulling at medical devices.
Recognizing acute changes and immediate physical threats is critical for nursing prioritization.
2
Determine the least restrictive intervention that ensures immediate client safety.
The nurse must remain at the bedside to physically prevent the client from pulling the catheter or falling out of bed.
Nursing standards mandate using the least restrictive measures to protect the client prior to considering chemical or physical restraints.
3
Evaluate the appropriate nursing scope of practice regarding the etiology of the symptoms.
The registered nurse must personally assess the client for physiological causes of the delirium rather than delegating the assessment or dismissing it as normal aging.
Initial assessments cannot be delegated, and sudden cognitive changes require immediate clinical investigation.

Anahtar Kavram

Accident, Error, and Injury Prevention (Restraint Alternatives and Safety Prioritization)
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Konular

Accident, Error, and Injury Prevention

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