The nurse plans a restraint-free environment but cannot find activities to engage an agitated middle-aged patient. Which should the nurse implement to maintain the patient's safety?

Question

a. Request help from interdisciplinary team members.
b. Transfer the patient to a private room to protect others.
c. Document that the patient is uncoopera-tive and hostile.
d. Ask the healthcare provider for a sedation prescription.

Answer 1

A
A nurse's expertise does not include occupational therapy, so the nurse collaborates with other experts to meet the patient's safety and psychosocial needs. After assessing the patient, the ex-perts make recommendations, and the nurse incorporates the activities into the patient's plan of care. Putting the patient in a private room decreases the risk of injury to other patients; but it iso-lates the patient, increases the need for distraction, and increases the risks to the staff and patient. Documentation should always be descriptive and never judgmental. In this case the nurse would document: "The patient stated, ‘Stay away.'" Sedation increases the risk of falls from potential adverse effects, including hypotension, dizziness, and confusion.