A nurse admitting and orienting an older adult to the hospital unit discusses fall prevention and demonstrates the use of the call bell to the patient. The patient's daughter asks: "Why don't you just put up all the side rails to prevent my mother from getting out of bed by herself and falling. That should work, right?" What is the nurse's best response?

A. Assist with obtaining informed consent from the client.
Explanation: Informed consent is a critical aspect of healthcare procedures, but it requires the patient to have the capacity to understand and make decisions. In this scenario, the client is intubated and on mechanical ventilation, which might compromise their ability to communicate effectively. If the client lacks capacity, obtaining consent from the durable power of attorney (POA) is more appropriate.

B. Refer to the client's advance directive for a name.
Explanation: Advance directives, including the durable POA, provide guidance on a person's wishes for healthcare decisions when they are unable to communicate. However, the advance directive may not always specify a particular person's name for decisions related to specific medical interventions. The key consideration in this situation is to determine the current decision-making capacity and involve the appropriate decision-maker if needed.

C. Determine the client's inability to make reasonable decisions.
Explanation: This is the correct answer. In this scenario, the nurse should assess the client's capacity to make decisions. If the client lacks capacity, the durable POA can be activated to make healthcare decisions on behalf of the client. Capacity involves the ability to understand relevant information, appreciate the consequences of decisions, and communicate a choice.

D. Use the oral trail-making test to measure cognitive function.
Explanation: The oral trail-making test is a cognitive screening tool, but it may not be suitable in this critical care scenario with an intubated and mechanically ventilated patient. Moreover, the primary concern in this situation is determining the capacity to make healthcare decisions, which requires a more comprehensive evaluation than a specific cognitive function test. The focus should be on decision-making capacity rather than a cognitive assessment.

A. Ensuring ready access to a toilet or commode.

Explanation: Ensuring ready access to a toilet or commode for the client is a practical measure to address bowel incontinence. This proactive approach allows the client to respond to the urge to defecate promptly, reducing the risk of incontinence episodes.

B. Encouraging the intake of 1 L of water each day.

Explanation: While maintaining adequate hydration is important for overall bowel health, it may not directly address the issue of bowel incontinence.

C. Expecting a rapid and full recovery.

Explanation: The expectation of rapid and full recovery does not constitute a specific intervention for addressing bowel incontinence. The approach to managing bowel incontinence is typically individualized and may involve various strategies depending on the underlying causes.

D. Toileting the client 10 to 15 minutes after meals.

Explanation: Toileting the client after meals is a timing strategy that may help take advantage of the gastrocolic reflex, but it is only one aspect of a comprehensive program for managing bowel incontinence. Other interventions, such as dietary adjustments, exercise, and toileting schedules, may also be considered based on the client's specific needs.