A nurse is assisting with the admission of a client who has dementia related to a traumatic brain injury. Which of the following findings should indicate to the nurse that the client's condition is worsening?

Rationale:

A. While this may seem convenient, longer cords can create tripping hazards, particularly for older adults or those with mobility limitations. In assisted-living environments, reducing environmental risks is critical; adding a long cord increases the chance of falls, which can result in serious injury. Safe fall-prevention strategies emphasize keeping walkways clear of obstacles and avoiding unnecessary extensions of objects that could interfere with mobility.

B. Armrests on chairs provide leverage and stability when residents sit down or stand up. Chairs without armrests can make it difficult for individuals with reduced strength, balance issues, or joint problems to safely transfer, increasing the risk of falls. Proper seating should include stable chairs with armrests at an appropriate height to support independent movement.

C. Bathrooms are high-risk areas for falls due to wet surfaces and slippery floors. Handrails or grab bars provide stable points of support for entering, exiting, and moving within the bathroom. Their use helps residents maintain balance and confidence, reducing the risk of slips and falls. This is a primary recommendation in fall-prevention programs for older adults in assisted-living or home settings.

D. Throw rugs are inherently unstable and prone to slipping, and placing them over cords creates a compounded hazard. This can cause residents to trip and fall, potentially resulting in fractures or head injuries. Fall-prevention teaching emphasizes removing loose rugs and securing cords safely along walls or with cord covers rather than covering them with unsecured rugs.

Rationale:

A. While the client’s medical history provides valuable background, it is considered secondary data because it was collected previously and may not reflect the client’s current condition, preferences, or symptoms. Reliance solely on the medical history can lead to incomplete or outdated information.

B. Progress notes from prior care providers also serve as secondary data. They summarize assessments and interventions but may not capture the client’s current subjective experience or immediate concerns.

C. Family input can be helpful, especially if the client is unable to communicate, but it is considered secondary information and may be influenced by the family’s perceptions, potentially differing from the client’s own experience.

D. The client is the primary source of data about their health, symptoms, and concerns. Direct communication with the client ensures that the nurse collects accurate, up-to-date subjective information, which is critical for forming an individualized plan of care. Even when secondary sources are used to supplement information, the client’s own account is prioritized whenever possible.