A client tells the nurse that he suspects that he grinds his teeth at night. Along with giving the client a dental referral, the nurse should explain that the client should see a dentist for this problem, which she should document as which of the following disorders?

A. Offer to request a prescription for an indwelling urinary catheter.

Indwelling urinary catheters carry risks, including the risk of infection, and should not be used solely for the purpose of addressing the fear of falling. Catheter use should be based on medical necessity.

B. Keep a night light on in the client’s room.

This is the most appropriate action. Keeping a night light on can help the client navigate the new surroundings more safely and reduce the risk of falls due to disorientation.

C. Limit the client’s fluid intake in the evening.

Limiting fluid intake, especially in the absence of a medical indication, may lead to dehydration and is not the best solution for addressing the fear of falling.

D. Put the side rails up and tell the client to call for assistance to the bathroom.

While encouraging the client to call for assistance is important, putting all four side rails up can be considered a restraint. Restraints should be avoided whenever possible to promote mobility and independence. It's important to balance safety with maintaining the client's autonomy.

A. Provide a diet high in protein.

During the oliguric phase of acute kidney injury (AKI), there is a risk of electrolyte imbalances, including elevated levels of blood urea nitrogen (BUN) and creatinine. Restricting protein intake is often recommended during this phase to manage azotemia and prevent the accumulation of waste products that the kidneys may struggle to excrete.

B. Provide ibuprofen for retroperitoneal discomfort.

Ibuprofen and other nonsteroidal anti-inflammatory drugs (NSAIDs) are contraindicated in AKI. They can further compromise renal function and may contribute to acute tubular necrosis. NSAIDs can also affect renal blood flow, leading to worsening kidney function.

C. Monitor intake and output hourly.

Monitoring intake and output (I&O) is a critical nursing intervention during the oliguric phase of AKI. Hourly monitoring helps assess renal function, fluid balance, and the effectiveness of interventions. It allows for early detection of changes that may require prompt intervention.

D. Encourage the client to consume at least 2 L of fluid daily.

In the oliguric phase of AKI, fluid intake is often restricted to prevent fluid overload. Encouraging excessive fluid intake may contribute to fluid retention and worsen the oliguria. Fluid management is carefully regulated based on the individual client's needs and renal function.