Examkin

Soru

Zorluk: KolayAccident, Error, and Injury Prevention

An older adult client with moderate dementia is admitted to the medical-surgical unit. During the night, the client repeatedly wanders out of the room, creating a significant risk for falls. Which initial action should the nurse take to promote client safety?

  1. Activate a bed alarm system to alert the nursing staff when the client attempts to exit the bed.Cevap
  2. B
    Apply soft wrist restraints to ensure the client remains safely in bed throughout the night.
  3. C
    Delegate the task of performing hourly neurological and cognitive assessments to the unlicensed assistive personnel (UAP).
  4. D
    Ask the client why they are constantly trying to leave the room in the middle of the night.

Cevap

The correct answer is to activate a bed alarm system to alert the nursing staff when the client attempts to exit the bed.
Activating a bed alarm is the most appropriate initial intervention because it is a safe, non-invasive, and least restrictive alternative to physical restraints. It immediately alerts healthcare staff when the client attempts to move, allowing for rapid intervention to prevent falls while maintaining the client's freedom of movement and dignity.

Adım Adım Çözüm

1
Identify the primary safety risk presented in the clinical scenario.
The client has dementia and is wandering at night, placing them at a high risk for falls and injury.
Recognizing the specific hazard dictates which safety protocols must be initiated.
2
Evaluate the interventions based on the principle of least restrictive restraints.
A bed alarm provides immediate notification to staff without physically restricting the client's movement.
Nursing standards mandate that the least restrictive measures must be exhausted before considering physical or chemical restraints.

Anahtar Kavram

Restraint Alternatives and Fall Prevention
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Konular

Accident, Error, and Injury Prevention

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