The charge nurse is preparing for the admission of an elderly client with delirium and agitation associated with urinary tract infection. To promote client safety, which intervention is most important for the charge nurse to implement?

Question

Quizplus · Accepted Answer

Client and staff safety is an ongoing concern when working with clients who are confused and agitated. The least restrictive restraint should be used. One-on-one supervision provided by a trained staff member who stays with the client at all times can promote safety while reducing or eliminating the use of restraints on a client who is confused and agitated. Frequent reassurance, touch, and verbal orientation (regarding name, location, time, and the client's situation) can lessen disruptive behaviors. Placing a large clock and calendar within the client's visibility would also help. (Option A) Ideally, the client will be placed in a room near the nursing station. However, the client with delirium and agitation will also require ongoing supervision to minimize harm to self or others. (Option B) Four-point leather restraints are one of the most restrictive restraint options. These are not appropriate as a first-line option for promoting safety. (Option C) Reducing environmental stimuli is important for an agitated client, but these alone are not most helpful. Educational objective: When caring for clients with behavioral issues that may compromise safety, less restrictive restraint and safety options should be implemented before more restrictive restraint options are used.

The Charge Nurse Is Preparing for the Admission of an Elderly