Progressive Care Nursing Certification (PCCN) Practice Exam

For a confused patient who requires safety measures, what action should the nurse take first?

1. Put a vest restraint on the patient

2. Ask a family member to stay with the patient

3. Administer a mild sedative

4. Increase the frequency of patient observation

The correct answer is: Increase the frequency of patient observation

In the scenario of a confused patient requiring safety measures, the priority action is to increase the frequency of patient observation. This approach allows the nurse to maintain close monitoring of the patient, ensuring their safety without the immediate need for restraints or medication. Enhanced observation can help prevent potential harm that might arise from the patient's confusion, such as wandering off, falls, or self-harm. Increasing observation can be achieved by sitting with the patient, using a camera monitoring system, or assigning additional staff to keep a close eye on the patient. This method is therapeutic and proactive, focusing on the patient's immediate safety needs without the use of physical restraints or sedatives, which could further complicate their condition and lead to other issues, such as increased agitation or discomfort. By prioritizing observation, the nurse can effectively assess the patient's behavior and respond quickly to any emerging issues, thereby promoting a safer environment and establishing a foundation for further interventions if necessary.