Practice Question
The nurse is caring for a client who is confused and at risk for falls. Which action should the nurse take first?
Answer Choices:
Correct Answer:
Initiate the bed alarm system.
Rationale:
🟦 Initiating a bed alarm system is the safest and least restrictive first intervention, which aligns with fall-prevention best practices.
🟦 The alarm gives immediate notification when the confused client attempts to get out of bed, reducing the likelihood of an unassisted fall.
🟦 This action can be performed independently by the nurse and does not require a provider’s order, allowing for rapid implementation.
🟦 Bed alarms support continuous monitoring, especially when the client has impaired judgment or cannot call for help.
🟦 This intervention preserves client autonomy while still ensuring safety, making it the most appropriate first step.
Sit the client at the nurses' station
🟦 Sitting the client at the nurses’ station may offer short-term supervision, but it does not provide consistent monitoring, especially during busy periods.
🟦 This strategy exposes the client to a high-stimulation environment, which may worsen confusion or agitation.
🟦 It is less reliable than an alarm system because nurses cannot observe the client continuously.
🟦 Moving the client frequently may increase fall risk during transfers.
🟦 It is not the safest or most efficient initial intervention compared to activating a bed alarm.
Place the client in soft wrist restraints
🟦 Restraints are considered a last resort and are among the most restrictive fall-prevention measures.
🟦 They require a provider order, strict monitoring, and documentation, so they cannot be applied immediately.
🟦 Restraints increase the risk of injury, agitation, and psychological distress, especially in confused clients.
🟦 Using restraints first violates the principle of implementing the least restrictive option.
🟦 They should only be considered after all other safety methods fail, making this an inappropriate first action.
Ask the healthcare provider for a sedative
🟦 Sedatives increase the risk of oversedation, respiratory depression, and paradoxical agitation in confused clients.
🟦 They do not prevent falls and may actually increase instability and delirium.
🟦 Medication is not a first-line fall intervention due to significant safety and ethical concerns.
🟦 Sedation masks changes in neurological status, making assessment more difficult.
🟦 Nonpharmacologic interventions must be attempted first before considering sedatives.
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This question is from EXAMPLIFY RN W4 NR224.NR229 Exam 1 which contains 57 questions.
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Question Details
- Category: RN Nursing Exam(s)
- Subcategory: Examplify Exam(s)
- Domain: Fundamentals
- Answer Choices: 4