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    ATI 133 Mental Health Final Proctored Exam

    Which of the following actions should the nurse take to address the safety needs of an older adult client who was alert and oriented at admission but now seems increasingly restless and intermittently confused?

    Explanation & Rationale

    Choice A reason:Moving the client to a room closer to the nurse's station is a non-invasive measure that allows for closer observation and quicker intervention if the client's condition worsens. It provides safety without compromising the client's autonomy or dignity.Choice B reason:Applying wrist and leg restraints is generally considered a last resort due to the potential for physical and psychological harm. Restraints can increase agitation and confusion, and they carry a risk of injury. They should only be used when less restrictive measures have failed and the client is at immediate risk of harm to themselves or others.Choice C reason:Administering medication to sedate the client may be appropriate in certain situations, but it should not be the first action taken. Sedation can mask underlying conditions and may lead to further complications. It is important to assess the cause of the client's restlessness and confusion before considering sedation.Choice D reason:Calling the family to ask them to stay with the client can provide comfort and may help to orient the client. However, this may not always be feasible, and it does not address the immediate safety needs of the client in the same way that moving them closer to the nurse's station does.

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