The nurse identifies the diagnosis Risk for Injury as appropriate for a client with metabolic acidosis. Which strategies should the nurse use to support this diagnosis?
Select all that apply.
A) Apply wrist restraints and secure to the bed frame.
B) Discuss chemical restraint use with the healthcare provider.
C) Keep the bed in the lowest position.
D) Keep bed side rails raised.
E) Place a clock and calendar at the bedside.
Answer: C, D, E
To reduce the client's risk for injury, the nurse should make sure the bed is kept in the lowest position and the side rails are raised. A clock and calendar at the bedside will help with orientation. Restraints are used in the event the client demonstrates harm to self or others. Confusion or a Risk for Injury is not a reason to use wrist or chemical restraints.
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1. assessment 2. diagnosis 3. implementation 4. evaluation
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