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    Ati 0926 Beg Med Surg Proctored Exam Cms Equivalent

    A nurse is caring for an older adult client who was alert and oriented at admission, but now seems increasingly restless and intermittently confused. Which of the following actions should the nurse take to address the client's safety needs?

    Explanation & Rationale

    A. Administer medication to sedate the client: Sedation is not an appropriate first-line intervention for acute confusion or restlessness in older adults. It increases the risk of falls, worsens delirium, and can mask underlying causes of the mental status change. B. Move the client to a room closer to the nurses' station: Relocating the client near the nurses’ station allows for closer monitoring and quicker intervention if the client becomes agitated or attempts unsafe behaviors. This enhances safety while avoiding unnecessary restraints or medications. C. Apply wrist and leg restraints to the client: Physical restraints should be used only as a last resort due to risks of injury, increased agitation, and ethical concerns. In this situation, less restrictive safety measures should be prioritized first. D. Call the family and ask them to stay with the client: Family presence may help calm and reorient the client, but it should not be the primary strategy for safety. Relying solely on family members shifts responsibility away from nursing staff and does not ensure consistent monitoring.

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