NCLEX-PN® ExaminationSafety and Infection ControlHard
A client on a medical-surgical unit suddenly becomes confused and attempts to climb out of bed. The LPN's initial action should be to:
- AAssess the client for potential causes of confusion and implement less restrictive interventions.
- BPlace the client in a room closer to the nursing station and raise all side rails.
- CCall the physician for a restraint order.
- DApply wrist restraints immediately to prevent a fall.
Show answer & explanationAnswer & explanation
Correct answer: A. Assess the client for potential causes of confusion and implement less restrictive interventions.
The LPN's initial priority is to assess the client's condition and implement the least restrictive interventions first to ensure safety. Confusion can be caused by various factors (e.g., medication side effects, infection, hypoxia), and addressing the underlying cause is crucial. Restraints are a last resort and require a physician's order.
Why the other options are wrong
- B. Moving the client and raising side rails are interventions, but they do not address the *cause* of the confusion and raising all side rails can sometimes be considered a restraint.
- C. While a physician's order is needed for restraints, it is not the *initial* action. Assessment and less restrictive measures come first.
- D. Restraints are a last resort and require a physician's order; immediate application without assessment is inappropriate.
Least Restrictive Interventions
Nursing interventions that maintain client safety while allowing the greatest possible freedom and autonomy.
- Always the first choice before considering restraints.
- Examples: reorientation, call light within reach, bed alarms, diversional activities.
- Requires thorough assessment to identify and address underlying causes of unsafe behavior.
Memory trick: Confused Client? Assess, Then Guide, Don't Just Tie!