An older adult client had hip replacement surgery 1 day ago, and the nurse thinks that the client is also demonstrating dementia. Which client assessment does the nurse use to determine whether this client is experiencing pain?

Choice A reason: Call for someone to bring the sign is not the most important intervention, as it does not address the immediate safety needs of the client. The sign is only a visual reminder of the fall risk, but it does not prevent the client from getting out of bed without assistance.

Choice B reason: Ensure he can reach his personal items is not the most important intervention, as it does not address the potential reasons for the client to get out of bed. The personal items may not include the items that the client needs, such as a phone, a book, or a snack.

Choice C reason: Instruct the client to use the call bell for help is the most important intervention, as it can prevent the client from falling and injuring themselves. The call bell is a device that allows the client to communicate with the nurse and request for help when needed. The nurse should educate the client about the importance of using the call bell and the risks of getting out of bed without assistance.

Choice D reason: Provide a urinal and drinking water is not the most important intervention, as it does not address the possible causes of the client's fall. The client may not need to use the urinal or drink water at the moment, or they may have other needs that are not met by these items.

Choice E reason: None of the above is not the correct answer, as there is one choice that is the most important intervention for the nurse to implement to prevent this event.

Choice A reason: Scabies is a skin infestation caused by tiny mites that burrow into the skin and lay eggs. It causes intense itching and a pimple-like rash, usually in the folds of the skin, such as the armpits, groin, or between the fingers. Scabies is highly contagious and can spread through direct skin contact or shared clothing or bedding.

Choice B reason: Herpes zoster, also known as shingles, is a viral infection that affects the nerves and the skin. It causes a painful, blistering rash that usually appears on one side of the body or face. Herpes zoster is caused by the same virus that causes chickenpox, which can reactivate later in life, especially in older adults or people with weakened immune systems.

Choice C reason: Skin cancer is an abnormal growth of skin cells that can be caused by exposure to ultraviolet (UV) radiation from the sun or tanning beds. It can appear as a new or changing mole, a sore that does not heal, or a scaly or crusty patch of skin. Skin cancer can vary in appearance, size, shape, and color, depending on the type and stage of the cancer.

Choice D reason: Actinic keratosis is a precancerous skin condition that is caused by chronic sun damage. It appears as rough, scaly, or crusty spots on the skin, usually on the face, ears, scalp, or hands. Actinic keratosis can sometimes develop into squamous cell carcinoma, a type of skin cancer, if left untreated.