A nurse is assisting with the care of a client who has delirium. The client is disoriented and restless. Which of the following conditions should the nurse identify as a risk factor for delirium?

Choice A reason: Blaming assistive personnel is subjective and speculative, not factual documentation. Falls may have multiple causes—mobility or environment—not just slippers. Legally and scientifically, records require objective data, not assumptions, to ensure accurate care planning and avoid liability missteps in clinical reporting.

Choice B reason: Quoting the client’s account provides objective, firsthand data about the fall’s circumstances—loss of balance during transfer. This factual detail aids in assessing risk factors like mobility or weakness, aligning with scientific documentation standards for precision and relevance in medical records.

Choice C reason: Incident reports are separate from medical records; mentioning one here is inappropriate. It’s an administrative action, not clinical data, and risks redundancy. Scientifically, records focus on patient status, not process notes, ensuring clarity for care continuity over procedural documentation.

Choice D reason: "Does not appear" is vague, not definitive, lacking objective findings like "no bruising noted." Documentation requires specific observations for accuracy. Scientifically, imprecise language weakens care planning, as it fails to confirm injury status with measurable evidence needed for clinical decisions.

Choice A reason: Using a trapeze builds upper body strength, aiding transfers and mobility post-amputation. Scientifically, this promotes independence by enhancing muscle power for prosthetic use, aligning with rehabilitation goals to restore function and reduce reliance on others early in recovery.

Choice B reason: Abduction with a pillow prevents adduction contractures but doesn’t directly enhance mobility. It’s passive, not active, support. Scientifically, while useful, it lacks the progressive impact of strength training, making it secondary to fostering independence in amputation care.

Choice C reason: Avoiding prone position is outdated; prone lying prevents hip flexion contractures, aiding mobility. Scientifically, this caution hinders rehabilitation, as stretching the hip flexors supports prosthetic alignment and walking, contradicting progression toward independence.

Choice D reason: Loose dressings don’t promote mobility; tight, controlled dressings reduce edema for prosthetic fitting. Scientifically, this delays healing and strength-building, as proper wound management, not loose coverage, supports physical progression in amputation recovery.