A registered nurse in the United States is caring for a patient who is confused and repeatedly tries to leave the unit. The patient is not violent and has no restraint order. Which action is most appropriate first?

Correct answer: C. Assess the cause of the confusion and use safety measures

  • A. Apply wrist restraints to prevent the patient leaving
  • B. Ask security to return the patient to the room
  • C. Assess the cause of the confusion and use safety measures
  • D. Tell the patient that leaving will cause loss of treatment

Explanation

The nurse should assess reversible causes of confusion and use the least restrictive safety measures, such as observation and environmental support. Restraints are not a first response to wandering and require legal and facility safeguards. Threats and unnecessary security involvement do not address the patient's clinical needs.

Submitted by a TestUstad contributor and published by the TestUstad editorial teamLast updated
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