A nurse is caring for an older adult client who was alert and oriented at admission but now seems increasingly restless and intermittently confused. Which of the following actions should the nurse take to address the client’s safety needs?
A.
Administer medication to sedate the client.
B.
Call the family and ask them to stay with the client.
C.
Apply wrist and leg restraints to the client.
D.
Move the client to a room closer to the nurses’ station.
The Correct Answer and Explanation is:
The correct answer is D. Move the client to a room closer to the nurses’ station.
Explanation:
When an older adult client who was previously alert and oriented begins to exhibit increasing restlessness and intermittent confusion, it is crucial to address their safety needs effectively. Here’s a detailed breakdown of the options:
A. Administer medication to sedate the client:
Sedation should not be the first line of action in managing restlessness and confusion. While medication may sometimes be necessary, it is generally considered a last resort due to potential side effects and the risk of worsening confusion or agitation. It’s important to first identify and address any underlying causes of the client’s symptoms, such as infection, dehydration, or metabolic imbalances, before resorting to sedatives.
B. Call the family and ask them to stay with the client:
While having family members present can provide comfort and reassurance to the client, it does not address the immediate safety concerns related to their increased restlessness and confusion. Family members cannot provide the constant supervision and intervention needed to ensure the client’s safety in a hospital setting.
C. Apply wrist and leg restraints to the client:
Restraints should be avoided whenever possible as they can lead to physical and psychological harm, including increased agitation and injury. Restraints are only appropriate when all other less restrictive measures have been exhausted and there is an immediate risk of harm to the client or others. Additionally, restraints require a physician’s order and should be used with caution.
D. Move the client to a room closer to the nurses’ station:
This option is the most appropriate and effective in addressing the client’s safety needs. By moving the client to a room closer to the nurses’ station, the client will be more closely monitored, allowing for timely interventions if their condition worsens. Increased visibility and proximity to the nursing staff can help prevent accidents or injuries that may result from the client’s restlessness and confusion.
In summary, moving the client to a room closer to the nurses’ station ensures enhanced observation and a quicker response to any sudden changes in the client’s condition, addressing their immediate safety needs effectively.