A nurse is assessing an older adult client’s risk for falls.
Which assessments should the nurse use to identify the client’s safety needs? (Select all that apply)

Choice A rationale

Assisting the patient into a prone position is not necessary for the use of thigh-length sequential compression sleeves. These devices are typically used while the patient is in bed or sitting in a chair.

Choice B rationale

Placing a sleeve over the top of each leg with the opening facing up is not the correct method for applying sequential compression sleeves. The sleeves should be applied so that they fit snugly and comfortably around the patient’s legs.

Choice C rationale

The nurse should ensure that two fingers can fit under the sleeves. This is to ensure that the sleeves are not too tight, which could impede blood flow and cause discomfort or injury to the patient.

Choice D rationale

Setting the ankle pressure at 65 mm Hg is not related to the use of sequential compression sleeves. The pressure settings for these devices are typically determined by the healthcare provider based on the patient’s specific needs.

Choice A rationale

Biofeedback is a mind-body technique that helps individuals gain control over bodily processes that are normally involuntary. It is not contraindicated for a client with herpes zoster.

Choice B rationale

Aloe is a plant-based product often used for its soothing and healing properties. It is not contraindicated for a client with herpes zoster.

Choice C rationale

Feverfew is a medicinal herb often used for its anti-inflammatory properties. It is not contraindicated for a client with herpes zoster.

Choice D rationale

Acupuncture involves the insertion of thin needles into specific points on the body. It is contraindicated for a client with herpes zoster because it could potentially open a portal on the skin’s surface, increasing the risk of further infection.