The caregiver of an older adult client who has Alzheimer's disease and is being cared for at home reports a history of previous falls. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)

Position the mattress on the floor.

Encourage physical activity prior to bedtime.

Install sensor devices on outside doors.

Remove loose rugs and clutter from walkways.

Ensure adequate lighting in hallways and bathrooms.

Answer and Explanation

Correct Answer : A,C,D,E

Choice A reason: Placing the mattress on the floor reduces the risk of injury from falls out of bed, especially for clients who are prone to wandering or disorientation at night.

Choice B reason: Encouraging physical activity before bedtime may increase agitation and disrupt sleep patterns in clients with dementia. Calming routines are preferred.

Choice C reason: Sensor devices on doors help monitor wandering behavior and alert caregivers, enhancing safety and preventing elopement.

Choice D reason: Removing loose rugs and clutter minimizes tripping hazards and supports a safer environment for clients with impaired mobility and judgment.

Choice E reason: Adequate lighting reduces confusion and helps prevent falls, especially during nighttime trips to the bathroom or when navigating unfamiliar spaces.

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Correct Answer is A

Explanation

Choice A reason: This response upholds HIPAA and nursing ethical standards by refusing to confirm or deny any information about a client. It protects confidentiality fully.

Choice B reason: Suggesting contact with the hospital may indirectly confirm the person is hospitalized, breaching confidentiality.

Choice C reason: Redirecting to the high school is irrelevant and does not address the confidentiality concern appropriately.

Choice D reason: Offering any information, even vague reassurance, violates confidentiality and professional boundaries.

A. A nurse checks a sleeping client’s blankets for safety. B. A nurse takes the arm of a client to redirect them after they wander into another client’s room. C. A nurse tells a client they have been depressed due to a recent divorce. D. A nurse reminds a client of their medication schedule.

Correct Answer is C

Explanation

Choice A reason: Checking blankets for safety is a routine and appropriate nursing action. It ensures the client’s well-being without breaching boundaries.

Choice B reason: Redirecting a client with gentle physical guidance is acceptable when done respectfully and for safety purposes. It does not constitute a boundary violation.

Choice C reason: Sharing personal emotional experiences with a client crosses professional boundaries. It shifts focus from the client’s needs and may blur therapeutic roles.

Choice D reason: Reminding a client about medication is part of routine care and does not involve personal disclosure or inappropriate behavior.

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The caregiver of an older adult client who has Alzheimer's disease and is being cared for at home reports a history of previous falls. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)

Nursing Test Bank

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Correct Answer is C

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