A nurse is developing a plan of care for a client who is at risk for falls. Which of the following interventions should the nurse include?

Install a bed exit sensor pad at the foot of the client's bed.

Encourage the client to ambulate in compression stockings.

Raise all four side rails for the client at bedtime.

Place a raised toilet seat in the client's bathroom.

Answer and Explanation

The Correct Answer is D

A. Install a bed exit sensor pad at the foot of the client's bed. While a bed exit sensor pad can be useful, it is typically placed on the mattress near the client's hips or lower back, not at the foot of the bed. This placement ensures it detects movement when the client tries to get up, thereby alerting staff to provide assistance.
B. Encourage the client to ambulate in compression stockings. Compression stockings can help with circulation but do not directly address fall prevention. Additionally, they can be slippery on some surfaces, potentially increasing the risk of falls if proper footwear is not used.
C. Raise all four side rails for the client at bedtime. Raising all four side rails is considered a form of restraint and can increase the risk of injury if the client attempts to climb over them. It can also limit the client’s ability to get out of bed independently and safely.
D. Place a raised toilet seat in the client's bathroom. This intervention is appropriate for fall prevention. A raised toilet seat can help clients with mobility issues by making it easier to sit down and stand up, thereby reducing the risk of falls in the bathroom, which is a common site for falls.

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Correct Answer is D

Explanation

A. Instruct the client to take a sitz bath three times a week. While sitz baths may provide symptom relief, they are not a primary intervention for treating a UTI.
B. Request a prescription for gabapentin. Gabapentin is used for neuropathic pain, not for treating UTIs.
C. Encourage the client to drink 2 oz of grapefruit juice each day. Grapefruit juice is not recommended for UTIs; cranberry juice is often suggested instead.
D. Increase the client's fluid intake to 3 L each day. Increasing fluid intake helps flush bacteria from the urinary tract and is a key intervention in managing UTIs.

A. Decrease in heart rate B. Increase in vagal nerve tone C. Decrease in respiratory rate D. Increase in muscle tone

Correct Answer is D

Explanation

A. Decrease in heart rate: Acute pain typically causes an increase in heart rate, not a decrease.
B. Increase in vagal nerve tone: An increase in vagal nerve tone can actually result in a decreased heart rate and is not a direct indicator of acute pain.
C. Decrease in respiratory rate: Acute pain usually causes an increase in respiratory rate, not a decrease.
D. Increase in muscle tone: This is correct. An increase in muscle tone can indicate acute pain as the body tenses in response to pain.

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