At 10 PM, an older male resident is attempting to climb over the bedrails. Which inter-vention should the nurse implement first?
a. Talk to the resident about his behavior.
b. Call the physician and ask for sedation.
c. Apply a vest restraint onto the resident.
d. Get a companion to keep him in the bed.
A
Feedback
A Correct. The resident is expressing a need that the nurse can potentially deter-mine with gentle questioning.
B Incorrect. Pharmacological intervention can be necessary but should not replace careful evaluation and management of the underlying cause.
C Incorrect. Simply restraining the patient will not address the underlying problem, and imposition of restraints can trigger delirium. Applying a restraint is the last resort, and the nurse must consider the problems that accompany the application of restraints before doing so.
D Incorrect. Placing a companion in the room can be an effective method of keep-ing the resident safe if the companion can determine and meet the resident's needs.
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