An elderly patient tries to get out of bed frequently and is at risk of falling. What is the best nursing int… - AIIMS Delhi NO- 2019

AIIMS Delhi NO- 2019

Fundamental of Nursing

Medium

Appeared in: AIIMS Delhi NO- 2019

Explanation

This intervention prioritizes patient safety while adhering to the fundamental nursing principle of using the 'least restrictive environment'.
Lowering the bed height reduces the potential distance and impact of a fall, minimizing the risk of serious injury.
Placing the call bell within easy reach empowers the patient to request help, which can address the root cause of why they are trying to get out of bed (e.g., needing to use the toilet, pain, or thirst).
This approach promotes patient autonomy and dignity while maintaining safety.

Option A: Applying physical restraints is an extreme measure and should only be used as a last resort when all other less restrictive alternatives have failed. It can cause physical and psychological harm.
Option C: Leaving a patient who is at high risk for falls alone is considered negligence and abandons the nurse's duty of care.
Option D: Locking a patient's room is illegal, unethical, and constitutes false imprisonment. It also creates a severe safety hazard by preventing emergency access.

Clinical Relevance

Nursing practice connection: Use the key finding related to Patient Safety and Fall Prevention to guide bedside assessment, documentation, and the next nursing action.
A core nursing responsibility is to create a safe environment and prevent falls, which are a leading cause of morbidity and mortality in older adults.
Proactive care, such as implementing hourly rounding to check on pain, positioning, and toileting needs (often called the '4 Ps'), can significantly reduce the likelihood of a patient trying to get out of bed unassisted.
What if? If the patient is cognitively impaired and continues to attempt to get out of bed despite these measures, the next step would be to implement closer monitoring, such as a bed alarm or assigning a sitter, before even considering restraints.

How to Approach the Question

First, identify the keywords in the question: 'elderly patient,' 'risk of falling,' and 'best nursing intervention.' The term 'best' requires you to select the most appropriate action based on safety and nursing principles.
Evaluate each option against the principle of the 'least restrictive environment.' This principle dictates that you should use the least intrusive measures necessary to ensure patient safety.
Immediately eliminate options that are clearly unsafe, unethical, or illegal. 'Leave patient alone' is negligence, and 'Lock the room' is false imprisonment.
Compare the remaining options. 'Apply physical restraints' is a highly restrictive measure, while 'Lower bed height and keep call bell nearby' is a less restrictive, preventative safety measure.
Conclude that the least restrictive, proactive safety measure is the 'best' intervention.

Concept Tested & Keywords

Concept Tested: Patient Safety and Fall Prevention
Stem keywords: elderly patient, risk of falling, get out of bed
Lead-in keywords: best nursing intervention
Clinical cues: Age/sex group narrows the expected diagnosis, intervention, or normal reference range.