An older aphasic client has severe osteoarthritis, bilateral contractures of the lower extremities, and a stage IV pressure ulcer. The nurse practitioner prescribes analgesic medications to be administered around-the-clock, with as-needed doses to be administered as appropriate. What observation by the nurse would indicate that the pain regimen is effective? (Select all that apply.)

Choice A reason: Risk for injury is a potential nursing diagnosis for a client who recently experienced a stroke, but it is not the priority. Risk for injury is related to the possible complications of stroke, such as hemiparesis, hemiplegia, dysphagia, or sensory deficits, that may increase the risk of falls, aspiration, or pressure ulcers. However, these complications are secondary to the primary problem of altered cerebral perfusion, which is the cause of stroke.

Choice B reason: Altered cerebral perfusion is the priority nursing diagnosis for a client who recently experienced a stroke, because it is the most urgent and life-threatening problem. Altered cerebral perfusion is defined as a decrease in blood flow to the brain, which can result in ischemia, infarction, or hemorrhage of the brain tissue. This can lead to irreversible neurological damage, disability, or death. Therefore, the nurse should focus on restoring and maintaining adequate cerebral perfusion as the first priority.

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.