The nurse is caring for a patient who has dementia and has been getting up out of bed at night. What action by the nurse will be most therapeutic?
a. The nurse places all of the side rails in the up position.
b. The nurse raises the bed to a tall position to reduce the patient's ability to get out of bed.
c. The nurse obtains orders from the physi-cian to apply restraints at night.
d. The nurse places the mattress on the floor.
D
The patient who is attempting to get out of bed and is at risk for falls will need provisions made to increase safety. The most appropriate and safest action will be to place the mattress on the floor. The use of side rails can be considered a restraint and it can present an additional safety hazard. Placing the bed in a tall position is a safety hazard and should not be done. Restraints are to be the last option when caring for patients.
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