Which nursing intervention is the highest priority when caring for an impulsive,forgetful stroke patient with right-sided paralysis?

A) Complete a fall risk assessment such as the Hendrich II Fall Risk Model.
B) Utilize a bed alarm and respond immediately when it is triggered.
C) Place the call light within easy reach and remind the patient to use it.
D) Apply a soft restraint to the patient's left wrist to prevent getting out of bed.

Question

Brianna Watson · Accepted Answer

Final Answer : B, Explanation :  The nurse should utilize a bed alarm for the patient and respond immediately when it is triggered indicating that the patient is starting to get up.This way the nurse will be able to intervene before the patient is able to get out of the bed.The patient is already known to be a fall risk so completing an additional fall risk assessment is unnecessary.The patient is forgetful and likely will not remember to use the call light.Restraints should be used only as a last result as they can cause significant injury and distress to the patient.

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