Components to a cognitive assessment include which of the following? (Select all that apply.)

A. Encouraging the client to use a cane when ambulating is a positive preventive measure, promoting stability and support during walking.

B. Keeping the side rails up on the client's bed at night can be concerning.

While it might seem like a safety measure, using side rails can lead to entrapment or falls, especially for frail older adults. Side rails can create a false sense of security, and if the client tries to climb over them or gets caught between the rails, it can result in injury.

C. Keeping several low wattage night lights on in the evening is a good preventive measure, as it helps improve visibility and reduces the risk of falls during nighttime activities.

D. Installing wooden railings on the stairway to the bathroom is a positive preventive measure, enhancing stability and support during stair navigation.

A. "As the health care proxy, you are the one who makes the decisions. Let's call your mom's doctor."
Explanation: This response inaccurately suggests that the health care proxy has the authority to make decisions even when the client has decision-making capacity. The focus should be on the client's autonomy.

B. "I understand why you are so upset. I don't think she is doing the right thing either. Let us think together how we can change her mind."
Explanation: This response is inappropriate as it involves the nurse expressing a personal opinion and attempting to influence the client's decision. The nurse's role is to support the client's autonomy and facilitate communication between the client and their family.

C. "You will need to go to court and be declared a guardian."
Explanation: Involving the court and seeking guardianship is not warranted when the client has decision-making capacity. This option is not aligned with the principles of respecting the client's autonomy and decision-making capacity.

D. "Health care proxies only come into play when the individual can no longer make their own decisions. Your mother is able to make her own decisions. I suggest you talk with her."
Explanation: In this scenario, the client is cognitively intact and has decision-making capacity. As long as the older adult is able to make their own decisions, the health care proxy's role is not activated. The nurse appropriately advises the daughter to communicate directly with her mother about her concerns and decisions. This respects the autonomy of the client, who has the right to make decisions about their own healthcare as long as they have the capacity to do so.