A nurse is caring for a client with cognitive impairment.
Which of the following actions should the nurse take to enhance understanding?

Choice A rationale
Loosening the restraints and assessing the patient’s skin is important, but it should be done as part of a regular assessment and not as the first action. The nurse should first document the findings to ensure accurate and timely communication of the patient’s condition.
Choice B rationale
Documenting the findings in the patient’s chart is the correct action. Accurate documentation is essential for communicating the patient’s condition and any interventions performed. It ensures continuity of care and provides a legal record of the patient’s status and the care provided.
Choice C rationale
Continuing to monitor the patient without making any changes is not appropriate. The nurse should assess the patient’s condition and document the findings to ensure that any necessary interventions are performed promptly.
Choice D rationale
Applying ice packs to reduce swelling is not appropriate in this context. The nurse should first document the findings and then assess the need for any interventions based on the patient’s condition.

Choice A rationale
Tertiary prevention involves managing and rehabilitating patients with established diseases to prevent complications and improve quality of life. Referring a client to a specialist for further evaluation does not fit this category.
Choice B rationale
Primary prevention aims to prevent the onset of disease by reducing risk factors and promoting health. Referring a client to a specialist for further evaluation is not primary prevention.
Choice C rationale
Secondary prevention involves early detection and treatment of disease to prevent progression. Referring a client to a specialist for further evaluation fits this category as it aims to identify and address health issues early.
Choice D rationale
“Disease process” is not a recognized level of prevention. The correct levels are primary, secondary, and tertiary.