An older adult who is confused at night repeatedly tries to … | MyMerci
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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?
1Keep the room dark and quiet to promote uninterrupted sleep throughout the night.
2Place the bed in the lowest position, activate the bed alarm, and offer scheduled toileting.✓ Correct answer
3Raise all four side rails to prevent the client from getting out of bed unassisted.
4Apply bilateral soft wrist restraints and check skin integrity every 2 hours per protocol.
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.
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.