An older adult client has been admitted to a skilled nursing facility. Which of the following can be caused by physical restraints? (Select all that apply.)

Choice A reason: Encouraging the client to use a cane when ambulating is not a cause of concern for the home health nurse, as it is a way of providing support and stability for the client, and preventing falls or injuries.

Choice B reason: Keeping several low wattage night lights on in the evening is not a cause of concern for the home health nurse, as it is a way of improving the visibility and orientation for the client, and reducing the risk of tripping or stumbling in the dark.

Choice C reason: Keeping the side rails up on the client’s bed at night is a cause of concern for the home health nurse, as it is a way of restricting the client’s mobility and increasing the likelihood of entrapment, injury, or death. Side rails can also create a false sense of security and encourage the client to climb over them, which can result in falls or fractures.

Choice D reason: Installing wooden railings on the stairway to the bathroom is not a cause of concern for the home health nurse, as it is a way of enhancing the safety and accessibility for the client, and preventing falls or slips on the stairs.

Choice A reason: Grab bars in place are important for preventing falls, as they provide support and stability for the patient when moving around the room, especially in the bathroom. Grab bars can help the patient maintain their balance and avoid slipping or tripping.

Choice B reason: Appropriate footwear is important for preventing falls, as it can reduce the risk of slipping, sliding, or stumbling. Appropriate footwear should fit well, have non-skid soles, and be comfortable and easy to put on and take off.

Choice C reason: Outdoor grounds are not a factor in the patient care environment that should be routinely assessed to decrease the risk of falls, as they are not part of the indoor setting where most falls occur. However, outdoor grounds may pose a fall hazard for patients who go outside for recreation or therapy, and should be checked for uneven surfaces, obstacles, or slippery conditions.

Choice D reason: All four bed rails raised are not a factor in the patient care environment that should be routinely assessed to decrease the risk of falls, as they may actually increase the risk of falls and injuries. Bed rails may create a false sense of security, encourage the patient to climb over them, or entrap the patient between the rails and the mattress. Bed rails should be used only when indicated and with the patient's consent.

Choice E reason: None of the above is not the correct answer, as there are two factors in the patient care environment that should be routinely assessed to decrease the risk of falls.