A nurse is admitting a client who is at risk for falls to a medical-surgical unit. Which of the following actions should the nurse take?

Elevate full-length side rails on both sides of the client's bed.

Place the bedside table 0.9 m (3 feet) away from the bed.

Provide the client with a night light.

Keep the client's room temperature at 18° C (64.4" F).

Answer and Explanation

The Correct Answer is C

A. Elevating full-length side rails on both sides of the client's bed is not recommended, as it can increase the risk of injury if the client tries to climb over them or gets trapped between them.

B. Placing the bedside table 0.9 m away is unrelated to fall prevention.
C. A night light can help the client see better in the dark and avoid tripping or falling over objects.
D. Maintaining the room temperature is important for comfort but doesn't directly prevent falls.

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Correct Answer is C

Explanation

A. Dismissing concerns by suggesting that they won't need to worry with physical therapy is not therapeutic. It invalidates the client's feelings.
B. Discouraging the client from worrying may seem dismissive of their emotions and concerns.
C. Acknowledging and reflecting the client's concern about the future demonstrates empathy and encourages further discussion.
D. Asking why the client is concerned might make them feel defensive and does not validate their emotions.

A. Turn overhead lights to a bright setting. B. Ask the family if they wish to assist in washing the client's body. C. Remove the client's dentures for their family to keep. D. Leave the client's eyes open until the family views the body.

Correct Answer is B

Explanation

A. Turning overhead lights to a bright setting may not be appropriate as it can be discomforting for the family and doesn't align with providing respectful postmortem care.
B. Inviting the family to assist in washing the client's body can be a part of therapeutic postmortem care and can help the family members in their grieving process.
C. Removing dentures for the family to keep isn't typically part of postmortem care.
D. Leaving the client's eyes open until the family views the body may not be culturally appropriate and can be distressing for the family.

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A nurse is admitting a client who is at risk for falls to a medical-surgical unit. Which of the following actions should the nurse take?

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