A hospitalized client is confused and has been attempting to get out of bed despite being instructed to call for assistance. What is the most appropriate action for the nurse to take to protect the client from injury?
Activate the bed alarm and limit interventions to promote rest.
Offer frequent assistance and consider a sitter.
Lower the bed and leave the client to rest.
Apply physical restraints to prevent unsafe behavior.
Frequent assistance and supervision are essential to safeguard confused clients from injury, especially when they may not comprehend instructions like calling for help. Offering a sitter is a common fall-prevention intervention for at-risk patients. Physical restraints are a last resort and require specific orders as they can lead to harm, agitation, or ethical concerns. Lowering the bed reduces the severity of a fall but does not actively prevent unsafe behaviors. Activating a bed alarm is useful for alerting staff but should be implemented alongside direct interventions like scheduled assistance and supervision.
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