A confused patient was found wandering in the hallways several times during the shift. What is the most appropriate nursing intervention to prevent a fall by this patient?
a. Reassigning the patient to a room closer to the nursing station
b. Using an electronic monitor that sounds an alarm when the patient reaches a near-vertical position
c. Raising two or four side rails
d. Placing wrist restraint on the patient during the nighttime hours of sleep
B
Alarm devices warn nursing staff that a patient is attempting to leave a bed or chair unassisted. There are a variety of types, including a device with a knee band that sounds an alarm when the patient reaches a near-vertical position. An infrared type of alarm is affixed to a headboard or bed frame, allowing a patient to move freely within a bed. If a patient tries to leave the bed, the infrared beam detects motion and sends out an alarm tone. Moving the patient to a room closer to the nursing station does not solve the problem. Raising side rails has the potential to trap parts of the patient's body, producing a hazard. The use of side rails alone for a disoriented patient often causes more confusion and further injury. Restraints are not a solution to a patient problem, but a temporary means to patient safety. Restraints are a last resort to prevent injury.
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Answer:
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