What initial measure can the nurse implement to reduce risk of injury for a client with liver disease?

• A. Pad the side rails on the bed
• B. Raise all four side rails on the bed
• C. Apply soft wrist restraints
• D. Prevent visitors, so as not to agitate the client

Answer: (A)

The key idea is creating a safe environment to prevent injury in a patient who may be at risk for confusion or wandering due to liver disease. Padding the side rails provides a protective measure that reduces the chance of injury if the patient shifts position or bumps into the rails, without restricting movement or requiring a physician’s order. It’s a nonrestrictive safety step you can implement right away.

Raising all four side rails is a restraint-labeled approach. It limits the patient’s movement and typically requires an order and ongoing justification; it’s not the first-line safety measure to reduce injury risk. Soft wrist restraints carry even more restrictions and also need an order and careful monitoring. Preventing visitors doesn’t directly address the immediate safety risk and could deprive the patient of support, so it isn’t the appropriate initial measure to decrease injury risk.