A nurse is reviewing documentation for four older adult clients recently admitted to a skilled nursing facility. Which client should the nurse identify as having the highest immediate risk for fall-related injury?

A. Age-related decreased thirst perception: Older adults often experience a reduced sensation of thirst, which can lead to inadequate fluid intake. Low fluid intake contributes to chronic constipation, concentrated urine, and increased susceptibility to urinary tract infections.

B. Use of a bedside commode for toileting: While convenient, a bedside commode does not directly cause constipation or UTIs. It may influence toileting habits, but it is not a primary contributing factor to the symptoms described.

C. Increased dietary fiber intake: Higher fiber intake generally improves bowel regularity and prevents constipation. It is unlikely to contribute to the client’s chronic constipation and associated urinary issues.

D. Daily fluid intake of 2,500 mL: Adequate fluid intake at this level usually helps prevent constipation and urinary tract infections. The client’s symptoms suggest insufficient fluid intake, making this inconsistent with the clinical picture.

A. Document the findings and instruct the client to monitor symptoms: Simply documenting and monitoring ignores the urgency of the situation. Elevated intraocular pressure with acute symptoms suggests acute angle-closure glaucoma, which can lead to permanent vision loss if not treated immediately.

B. Administer prescribed analgesics and observe for symptom improvement: Analgesics may relieve pain but do not address the dangerously high intraocular pressure. This delays definitive treatment and risks rapid progression of optic nerve damage.

C. Notify the provider immediately and prepare the client for emergency treatment: Sudden headache, eye pain, blurred vision, and high intraocular pressure are hallmarks of acute angle-closure glaucoma. This is a medical emergency that requires urgent ophthalmologic intervention to prevent irreversible blindness.

D. Reassure the client and schedule an ophthalmology consult for the next day: Delaying care until the next day puts the client at high risk of permanent vision loss. Immediate emergency treatment is required rather than routine referral.