A nurse aide is assisting a resident who has a history of falls and is exhibiting increased confusion and restlessness. The nurse aide notes the resident attempting to climb out of bed. What is the most appropriate action for the nurse aide?
- ARaise all four side rails to keep the resident in bed.
- BStay with the resident and calmly redirect them, then notify the nurse.
- CLeave the room to get the nurse immediately.
- DApply a vest restraint to prevent the resident from falling.
Show answer & explanationAnswer & explanation
Correct answer: B. Stay with the resident and calmly redirect them, then notify the nurse.
For a confused and restless resident attempting to climb out of bed, the safest and most person-centered initial action is to stay with them, provide a calm presence, and redirect their attention. Raising all four side rails or applying restraints can increase agitation, is considered a restraint (requiring an order), and can lead to more serious injury if the resident attempts to climb over them. Notifying the nurse is crucial but only after ensuring immediate safety.
Why the other options are wrong
- A. Raising all four side rails is considered a restraint and can increase the risk of injury if the resident tries to climb over or through them.
- C. Leaving the resident unattended while they are trying to climb out of bed puts them at immediate risk of falling and injury.
- D. Applying a restraint without a physician's order is illegal and can cause harm; it should be a last resort after other interventions fail.
Managing Restlessness/Elopement Risk
Strategies for safely managing residents who are restless, confused, and attempting to leave their bed or unit, prioritizing non-restraint interventions.
- Stay with the resident to ensure immediate safety.
- Use verbal de-escalation and calm redirection.
- Identify and address underlying causes of restlessness (e.g., pain, need to use bathroom).
- Avoid physical restraints unless medically ordered as a last resort.
- Notify the nurse immediately for assessment and intervention planning.
Memory trick: Stay, calm, redirect, then inform, so no harm.