At 10 PM, an older male resident attempts to climb over the bedrails. Which intervention should the nurse implement first?
a. Talk to the resident about his behavior.
b. Call the physician, and ask for a sedative.
c. Apply a vest restraint on the resident.
d. Get a companion to keep him in the bed.
A
The resident is expressing a need that the nurse can potentially determine with gentle questioning. Pharmacological intervention can be necessary but should not replace careful evaluation and management of the underlying cause. Simply restraining the patient will not address the under-lying problem, and the 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. Placing a companion in the room can be an effective method of keeping the resident safe if the companion can determine and meet the resident's needs.
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