A nurse is assisting with the care of a client who has pneumonia.

For each potential nursing action, click to specify if the potential action is anticipated or contraindicated for the client.

A) Place the bedside table 2 feet away from the bed: This is not recommended for a client at risk for falls. The bedside table should be within reach of the client to avoid the need for excessive movement, which could increase the risk of a fall, especially if the client is unsteady or disoriented. Ideally, the bedside table should be placed within arm’s reach for convenience and safety.

B) Keep lighting in the home dim: Dim lighting increases the risk of falls by making it harder for the client to see obstacles and navigate safely. It is important to ensure that lighting is bright enough to illuminate walking areas, hallways, and other areas that might present a fall risk.

C) Place area rugs on slick floor surfaces: Area rugs on slick surfaces are hazardous as they can cause tripping or slipping, increasing the risk of a fall. It is best to remove rugs or ensure they are securely fastened to prevent them from sliding. Non-slip rugs or floor mats can be used, but they should not be placed on slick surfaces.

D) Move the client's bed to the main floor of the house: Moving the client's bed to the main floor is a good safety measure, especially if the client has difficulty navigating stairs. This reduces the need for the client to climb stairs, which can be dangerous and increase the risk of falls. Having the bed on the main floor ensures that the client can easily access their sleeping area without the risk of falling on stairs.

A) I have a difficult time getting my child to eat green vegetables: While it’s common for preschoolers to be selective about food, especially vegetables, this issue does not represent an immediate concern for the child’s health or development. This issue can often be addressed with strategies to encourage healthy eating, but it is not as urgent as other concerns.

B) My child continually asks me the same questions: Repetitive questioning is a normal part of preschool development, as children at this age are curious and often seek reassurance. It reflects their cognitive development as they try to understand the world around them. While it may be tiring for the guardian, it is not an immediate concern.

C) My child still wets the bed at least two times per week: Bedwetting (enuresis) is common among preschool-aged children, and many children do not gain full bladder control until after age 5. This issue is typically addressed if it continues past the age of 5, but it is not a priority at this time.

D) I have noticed that my child is withdrawn since we switched day care providers: This statement indicates a potential emotional or behavioral issue that requires immediate attention. Changes in behavior, such as withdrawal, can be a sign of stress, anxiety, or difficulty adjusting to a new environment. The nurse should prioritize this concern, as it may indicate that the child is having difficulty coping with the transition and may need additional support or evaluation. Addressing emotional well-being is a priority for the nurse.