For a cognitively impaired patient who cannot accurately report pain, which assessment tool would be most useful?

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: This is a correct answer because Alzheimer's disease affects the brain cells and causes them to degenerate and die. This leads to a gradual decline in cognitive abilities, such as memory, language, reasoning, and problem-solving.

Choice B reason: This is a correct answer because Alzheimer's disease interferes with the daily activities and routines of the affected person. They may experience a decline from their previous level of functioning, such as forgetting appointments, misplacing items, or getting lost.

Choice C reason: This is an incorrect answer because easily frustrated is not a specific outcome of the early stage of Alzheimer's disease. Although some people with Alzheimer's disease may become frustrated, irritated, or angry due to their cognitive impairment, this is not a universal or diagnostic symptom.

Choice D reason: This is a correct answer because Alzheimer's disease affects the short-term memory first, causing the person to forget recent events, conversations, or names. This is called mild memory loss, and it is one of the most common signs of the early stage of Alzheimer's disease.

Choice E reason: This is a correct answer because Alzheimer's disease affects the frontal lobe of the brain, which is responsible for executive functions, such as planning, organizing, decision-making, and judgement. This leads to impaired judgement, such as making poor financial choices, neglecting personal hygiene, or acting inappropriately.