An older adult who is confused at night repeatedly tries to … | MyMerci
Accident/Error/Injury PreventionSIPC
Question
An older adult who is confused at night repeatedly tries to get out of bed without assistance. Which nursing intervention is most appropriate?
1Place the bed in the lowest position, activate the bed alarm, and offer scheduled toileting.✓ Correct answer
2Apply wrist restraints so the client cannot get up.
3Keep all side rails raised to prevent movement.
4Leave the lights off so the client can sleep longer.
Explanation
Fall prevention should use least restrictive safety measures first, including low bed position, alarms, frequent rounding, and toileting. Restraints and full side rails can increase injury risk and require strict criteria. Darkness can worsen disorientation and fall risk.
In-depth explanation
Clinical Judgment Reduce fall risk while preserving mobility and using least restrictive interventions.
Memory Tip Low bed, alarm, toileting, light, rounding before restraints.
KR vs US NCLEX safety questions favor least restrictive interventions unless immediate danger requires escalation.
Clinical scenario
Clinical Practice Guide Fall prevention plans combine environment safety, toileting, alarms, visibility, mobility support, and reassessment of reversible causes.
Caution Use restraints only when less restrictive measures fail and policy criteria are met.
Key concepts
Fall Prevention — Interventions to reduce risk of accidental falls and related injury.
Least Restrictive — The safety approach that protects the client while preserving as much freedom as possible.
Bed Alarm — A device that alerts staff when a high-risk client attempts to leave bed.