The nurse is caring for an 80-year-old confused client in renal failure who is very weak. The client keeps trying to get out of bed. Which of the following would be the best safety device to use with this client?

Question

1. Place the client in a jacket restraint to prevent falling out of bed.
2. Ask the family to sit with the client around the clock.
3. Use a bed exit alarm device.
4. Frequently check on the client to ensure that the client is in bed.

Answer 1

3
Rationale 1: A bed exit alarm device is activated when the client attempts to get out of bed, and alerts the nursing staff. Restraints are demeaning, are more immobilizing than necessary, and could cause further injury if the client becomes twisted in the restraint. Having the family sit with the client does not relieve the nurse's responsibility for the client's safety, and places an unnecessary burden on the family. No matter how many times the nurse checks on the client, the client can fall getting out of bed in between checks.