What does a score of 6 on the Katz Index of Independence in Activities of Daily Living (ADLs) indicate?

A. Trochanter roll: A trochanter roll is used to prevent external rotation of the hips in clients who are immobilized, but it does not specifically address plantar flexion contractures of the feet.

B. Sheepskin heel pad: While a sheepskin heel pad can help prevent pressure ulcers on the heels, it does not actively prevent plantar flexion contractures. It is more focused on protecting the skin from friction and pressure.

C. Footboard: A footboard is the most appropriate device to prevent plantar flexion contractures. It provides support to the feet and helps keep them in a neutral position, reducing the risk of contractures developing in the calf muscles and Achilles tendon due to prolonged immobility.

D. Abduction pillow: An abduction pillow is used primarily to maintain the position of the legs after hip surgery and to prevent hip dislocation. It does not specifically prevent plantar flexion contractures.

A. Place a seat alarm in the client's chair: This action is the most appropriate first step. A seat alarm can alert the nurse if the client attempts to stand or leave the chair, allowing for timely intervention while promoting the client's dignity and autonomy. This approach aims to enhance safety without the use of restraints or medications.

B. Administer lorazepam to the client: While lorazepam may help manage agitation, it should not be the first action taken. Pharmacological interventions should be considered after non-pharmacological strategies have been explored. Additionally, administering medication requires careful assessment of the client’s current state and potential side effects.

C. Apply a vest restraint on the client: Restraints should be used only as a last resort and after all other options have been considered. Applying a vest restraint can lead to increased agitation and feelings of helplessness, which may exacerbate the client’s condition. The nurse should prioritize less restrictive interventions.

D. Place the client in bed with the two side rails raised: This action can pose safety risks, as raising side rails may create a false sense of security and could lead to falls if the client attempts to get out of bed. Additionally, confining the client to bed can lead to increased confusion and agitation. It is important to provide a safe environment that encourages mobility while minimizing the risk of falls.