A 79-year-old resident in a long-term care facility is known to “wande

A 79-year-old resident in a long-term care facility is known to “wander at night” and has fallen in the past. Which of the following is the most appropriate nursing intervention?

1. An abdominal restraint should be placed on the client during sleeping hours.
2. The client should be checked frequently during the night.
3. A radio should be left playing at the bedside to assist in reality orientation.
4. The client should be placed in a room that is away from the activity of the nurses’ station.

ANSWER

ANS: 2
Alternatives to restraints should be attempted first. (A physician’s order is required for restraints to be applied.) The most appropriate intervention is to check on the client frequently. Alternatives to restraints should be attempted first before an abdominal restraint while sleeping.
A radio may help orientate a client to reality. However, the most appropriate intervention for the client who wanders is to check on the client frequently. Clients who wander should be assigned to rooms near the nurses’ station and checked on frequently.