A nurse is assisting with teaching a class about physical manifestations associated with the fight-or-flight response to stress.
Which of the following manifestations should the nurse include?

This is a responsibility of the nurse in the process of informed consent, which is the patient’s choice to have a treatment or procedure based on their full understanding of its benefits, risks, and alternatives. The nurse should provide written materials in the client’s spoken language, when possible, and verify that the client comprehends and consents to the care and procedures.

Choice A is wrong because confirming that the client is competent to sign for the procedure is not a responsibility of the nurse, but of the health professional who directs the care. The nurse can only obtain consent when initiating care or reviewing consent before providing care ordered by another health professional.

Choice B is wrong because discussing the risks of the procedure with the client is not a responsibility of the nurse, but of the health professional who directs the care. The nurse can only inform the client about what will occur during the procedure and answer any questions they may have.

Choice D is wrong because explaining alternatives to the procedure to the client is not a responsibility of the nurse, but of the health professional who directs the care. The nurse can only inform the client about what will occur during the procedure and answer any questions they may have.

These actions ensure the safety of the client by reducing the risk of falls, confusion and injury.

Keeping a call bell within the client’s reach allows them to ask for help when needed.

Keeping a dim light on at night helps them orient themselves and see their surroundings.

Keeping unnecessary furniture out of the way prevents tripping and cluttering. Choice D is wrong because keeping all side rails up at all times can be considered a form of physical restraint, which is associated with many professional, legal and ethical challenges. Physical restraint should only be used as a last resort when other alternatives have failed or are not feasible. Keeping all side rails up can also increase the risk of injury if the client tries to climb over them.

Choice E is wrong because keeping all lights off at night can increase the risk of falls and confusion for the client.

Older adults may have impaired vision and cognition, and they may need to use the bathroom frequently at night. Keeping all lights off can make it difficult for them to find their way and increase their anxiety.