After assessing the older client in his bed, the nurse determines that he is at high risk for falls. The nurse leaves the room to get a fall risk sign and returns to find him on the floor pleading for help. Which of the following was the most important intervention the nurse should have implemented to prevent this event?

A. The Global Deterioration Scale

Explanation: The Global Deterioration Scale (GDS) is a tool used to assess the cognitive function and stage of cognitive decline in individuals, especially those with dementia.

B. Mini Mental State Exam (MMSE)

Explanation: The Mini Mental State Exam (MMSE) is a widely used tool to assess cognitive function and screen for cognitive impairment. It evaluates various cognitive domains, including orientation, memory, attention, and language.

C. Older American's Resources and Services (OARS)

Explanation: The Older American's Resources and Services (OARS) is not a cognitive assessment tool. It is a comprehensive assessment tool that covers various domains, including physical health, mental health, and social resources.

D. Mini-Cog

Explanation: The Mini-Cog is a brief cognitive screening tool that includes a three-item recall test for memory and a clock-drawing task. It is used to quickly assess cognitive function and detect potential cognitive impairment.

E. The Barthel Index

Explanation: The Barthel Index is not a cognitive assessment tool. It is a tool used to assess an individual's ability to perform activities of daily living (ADLs), providing information about their functional independence rather than cognitive status.

A. Driving in heavy traffic is fine as long as it is not raining.
Explanation: Driving in heavy traffic can pose challenges for individuals, especially those who may experience age-related changes in vision, reaction time, and cognitive function. The recommendation is to avoid heavy traffic, especially if it might increase stress and the likelihood of accidents.

B. If you have a passenger, you may drive at any time of the day.
Explanation: The presence of a passenger does not necessarily eliminate the potential challenges associated with age-related changes in driving abilities. It is important for older individuals to consider factors such as time of day, visibility, and overall driving conditions.

C. Limit driving to familiar places close to home.
Explanation: Limiting driving to familiar places close to home is a safer practice for older individuals who may face challenges with vision, reaction time, and other factors that can impact driving. Familiar routes are more likely to be navigated confidently, reducing the risk of getting lost or encountering unexpected challenges.

D. Playing music will help keep you alert.
Explanation: While playing music can be enjoyable, it may not be an effective strategy for maintaining alertness, especially during challenging driving conditions. The focus should be on adopting safe driving habits and minimizing distractions to ensure overall safety on the road.