A home health nurse is assessing the health history of a new client.
Which of the following conditions should the nurse identify as increasing the client’s risk for falls?

Choice A rationale

This statement indicates a concern about financial stability, which is a valid concern but does not necessarily indicate adaptation to the caregiver role.

Choice B rationale

While rearranging furniture to accommodate a walker is a positive step towards creating a safe environment for the client, it does not necessarily indicate that the caregiver has fully adapted to their new role. It shows an effort to modify the physical environment, but adaptation to the caregiver role involves more than just physical changes.

Choice C rationale

Apologizing for the dishes piling up in the kitchen sink may indicate feelings of overwhelm or stress, which are common in new caregivers. However, this statement does not necessarily indicate adaptation to the caregiver role.

Choice D rationale

This statement indicates that the caregiver is taking steps to maintain their own well-being while also caring for their loved one. By arranging for a neighbor to come over so they can take time for themselves, the caregiver is demonstrating an understanding of the importance of

self-care in their new role. This is a key aspect of adapting to the caregiver role.

Choice A rationale

Asking the client to describe how they are feeling today is an important part of the assessment. However, when dealing with a client who is managing depression, the nurse’s first priority should be to ensure the safety of the client.

Choice B rationale

Asking if the client is having any thoughts about hurting themselves is the first question the nurse should ask. This is because safety is always the top priority, and clients dealing with depression may be at risk for self-harm or suicide.

Choice C rationale

While it’s important to understand what makes the client feel less depressed, this question is not as immediately critical as assessing for potential self-harm or suicide risk.

Choice D rationale

Understanding the client’s support system is an important part of the assessment, but it is not the first priority. The nurse’s initial focus should be on assessing the client’s immediate safety and mental health status.