A nurse in a provider's office is caring for a client.

Exhibits

The nurse is performing a fall risk assessment for the client. Select the 3 findings that place the client at risk for a fall.

Rationale:

A. The client brushes her teeth twice daily: Brushing teeth at least twice a day is recommended to reduce plaque buildup, prevent tooth decay, and maintain oral health. This practice is consistent with standard personal hygiene guidelines.

B. The client wipes back to front when toileting: Wiping from back to front increases the risk of transferring bacteria from the anal area to the urethra, which can lead to urinary tract infections. The correct method is front to back.

C. The client washes her perineum first when bathing: The perineal area should be washed last to avoid transferring bacteria from this region to other parts of the body, especially the face. Washing it first increases the risk of cross-contamination.

D. The client takes a hot bubble bath every day: Daily hot bubble baths can dry out the skin and disrupt normal skin flora, potentially leading to irritation or infection. Mild, less frequent bathing with warm (not hot) water is healthier for skin integrity.

A. Observe the client's range of movement: While monitoring physical status is important, mechanical restraints restrict movement, so assessing the client’s psychological triggers and safety is higher priority to prevent further aggression.

B. Identify stressors that caused the client's aggression: Understanding and addressing the factors that led to aggressive behavior is essential while the client is in restraints. This assessment helps in developing strategies to reduce agitation and prevent future episodes.

C. Hold a critical incident debriefing about the client: Debriefing is conducted after the event to support staff and evaluate interventions. It is not performed while the client is actively restrained.

D. Maintain sensory stimulation for the client: Providing excessive sensory stimulation during restraint can increase agitation and risk of injury. The focus should be on calming the client and ensuring safety rather than maintaining stimulation.