A confused client repeatedly tries to climb out of bed. Which action should the nurse attempt before applying restraints?
1Apply wrist restraints because confusion is present.
2Leave the client alone to avoid increasing agitation.
3Use frequent observation, reorientation, and a low bed with alarms.✓ Correct answer
4Tell the client that restraints are required for all confused clients.
Explanation
Restraints are used only when less restrictive interventions fail and safety remains at risk. Reorientation, increased observation, environmental safety, and bed alarms are appropriate first steps. Confusion alone does not justify restraints.
Clinical Judgment Use the client cues, timing, labs, and safety risks to select the response that best fits Least restrictive fall prevention.
Memory Tip Match the strongest cue cluster to the safest nursing judgment.
KR vs US NCLEX items reward cue-based priority thinking rather than isolated recall.
Clinical Practice GuideFor Least restrictive fall prevention, compare the complete cue pattern with the client's current stability, ordered data, and expected nursing scope.
CautionDo not choose an action from one isolated cue when the full scenario changes priority or safety.
Restraint — A device or method that restricts a client's movement.
Least Restrictive Intervention — The safest option that preserves the most freedom possible.
Reorientation — Reminding a confused client of person, place, time, or situation.