After assessing the older client in his bed, the nurse determines that he is at high risk for falls. The nurse leaves the room to get a fall risk sign and returns to find him on the floor pleading for help. Which of the following was the most important intervention the nurse should have implemented to prevent this event?

A. "Use of drugs results in minimal improvement in appetite and weight gain and can have some serious side effects."

Explanation: It is important for the nurse to provide accurate and balanced information about the use of drugs to stimulate appetite. While there are medications available that may be prescribed to improve appetite in certain situations, it is crucial to convey that the effectiveness of such drugs is limited, and they can also have potential serious side effects. Additionally, the decision to use appetite-stimulating drugs should be carefully considered, taking into account the individual's overall health, medical conditions, and potential risks associated with the medications.

B. "There are no drugs that impact appetite or weight gain."

Explanation: This statement is not accurate, as there are medications that may impact appetite and weight gain. However, the effectiveness and appropriateness of such medications should be assessed on a case-by-case basis.

C. "These drugs are not permitted to be used in a long term care facility."

Explanation: This statement is not accurate. The use of appetite-stimulating drugs may be permitted in long-term care facilities, but their use is typically based on individual assessment and consideration of potential risks and benefits.

D. "Yes, there are some very effective drugs out there. Your mother should be on one of them."

Explanation: This statement oversimplifies the decision-making process and may not provide adequate information about the potential risks and benefits of appetite-stimulating drugs. The decision to use such drugs should be made in consultation with the healthcare team, considering the individual's specific circumstances.

A. Defecation less than once each day is not necessarily constipation.

Explanation: The frequency of bowel movements varies among individuals, and defecating less than once each day does not necessarily indicate constipation. Normal bowel habits can differ, and what is considered regular for one person may not be the same for another. Constipation is better assessed by considering other factors such as stool consistency, straining during bowel movements, and feelings of incomplete evacuation.

B. Leaking liquid feces should be treated as diarrhea.

Explanation: Leaking liquid feces may be indicative of diarrhea, but it is not the only factor to consider. The cause of diarrhea should be investigated, and treatment will depend on the underlying reason, which may include infections, medications, or other medical conditions.

C. Mineral oil is recommended as a laxative for the older adult.

Explanation: Mineral oil is generally not recommended as a laxative for older adults. It can interfere with the absorption of fat-soluble vitamins and may have adverse effects. There are other safer and more effective laxative options that healthcare providers may recommend.

D. Excessive sleep can be a symptom of constipation.

Explanation: Excessive sleep is not typically considered a symptom of constipation. Constipation is more commonly associated with symptoms such as infrequent bowel movements, difficulty passing stool, and abdominal discomfort. Sleep disturbances may have various causes, but they are not a direct symptom of constipation.