When teaching a client about foods that do not increase blood glucose, which should the nurse include?

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.

Choice A reason: Turning immobile clients every 2 hours off bony prominences can reduce the pressure and friction that can cause skin breakdown and ulcer formation.

Choice B reason: Using lift or draw sheets to move clients in bed can prevent dragging or pulling the skin, which can cause shear and damage the underlying tissue.

Choice C reason: Keeping the skin moist is not a correct way to prevent pressure ulcers. Moisture can weaken the skin and make it more prone to injury. The skin should be kept dry and clean, and moisturized if needed.

Choice D reason: Ensuring that your client maintains a healthy nutritional status can promote wound healing and prevent infection. Adequate protein, calories, vitamins, and minerals are essential for skin integrity and tissue repair.

Choice E reason: Applying pressure-relieving devices to vulnerable areas can distribute the pressure and protect the skin from damage. Examples of pressure-relieving devices are foam pads, air mattresses, or cushions.