# An older adult who is confused at night repeatedly tries to get out of bed without assistance. Which nursing intervention is most appropriate?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=393728&lang=en  
> language: en  
> subject: Accident/Error/Injury Prevention  
> category: SIPC

## Question

An older adult who is confused at night repeatedly tries to get out of bed without assistance. Which nursing intervention is most appropriate?

## Option

1. Place the bed in the lowest position, activate the bed alarm, and offer scheduled toileting. **✔ Correct answer**
2. Apply wrist restraints so the client cannot get up.
3. Keep all side rails raised to prevent movement.
4. Leave the lights off so the client can sleep longer.

**Correct answer: 1**

## 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.

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