Editing Infection Control and Safety – RN Practice Questions (section)

==Question 9==
A confused older adult client repeatedly attempts to climb out of bed. Which action should the nurse take '''first'''?
# Apply a vest restraint and notify the provider for an order.
# Raise all four side rails to keep the client in bed.
# Assess for pain, hypoxia, a full bladder, and recent medications, and move the client closer to the nurses' station.
# Administer the ordered as-needed lorazepam for agitation.

'''Answer:''' 3. Assess for pain, hypoxia, a full bladder, and recent medications, and move the client closer to the nurses' station.

''Rationale:'' Restraints are a last resort. The nurse first identifies and treats the cause of the behavior and applies the least restrictive intervention. Option 2 is a restraint and adds entrapment and fall-from-height risk. Options 1 and 4 are chemical and physical restraint, appropriate only after alternatives fail and only with a valid order; benzodiazepines also commonly worsen delirium in older adults.