For a cognitively impaired patient who cannot accurately report pain, which assessment tool would be most useful?

Choice A reason: Call for someone to bring the sign is not the most important intervention, as it does not address the immediate safety needs of the client. The sign is only a visual reminder of the fall risk, but it does not prevent the client from getting out of bed without assistance.

Choice B reason: Ensure he can reach his personal items is not the most important intervention, as it does not address the potential reasons for the client to get out of bed. The personal items may not include the items that the client needs, such as a phone, a book, or a snack.

Choice C reason: Instruct the client to use the call bell for help is the most important intervention, as it can prevent the client from falling and injuring themselves. The call bell is a device that allows the client to communicate with the nurse and request for help when needed. The nurse should educate the client about the importance of using the call bell and the risks of getting out of bed without assistance.

Choice D reason: Provide a urinal and drinking water is not the most important intervention, as it does not address the possible causes of the client's fall. The client may not need to use the urinal or drink water at the moment, or they may have other needs that are not met by these items.

Choice E reason: None of the above is not the correct answer, as there is one choice that is the most important intervention for the nurse to implement to prevent this event.

Choice A reason: Teaching the client alternative comfort measures is not the best recommendation for the nurse to implement, as it may imply that the client's pain is not taken seriously or that the nurse is reluctant to provide pain relief. The nurse would teach the client alternative comfort measures, such as relaxation techniques, distraction, or massage, as a supplement to the pain medication, not as a substitute.

Choice B reason: Telling the client that it is too soon for pain medication is not a good recommendation for the nurse to implement, as it may make the client feel dismissed, ignored, or judged. The nurse would follow the prescribed pain medication schedule, but also consider the client's individual needs and preferences, and adjust the dosage or frequency as needed, with the doctor's approval.

Choice C reason: Administering the pain medication as requested by the client is not a safe recommendation for the nurse to implement, as it may cause overdose, addiction, or adverse effects. The nurse would administer the pain medication as prescribed by the doctor, and monitor the client's response, side effects, and vital signs.

Choice D reason: Validating the pain with other assessment data is the best recommendation for the nurse to implement, as it shows respect, empathy, and professionalism. The nurse would acknowledge the client's pain, ask about the location, intensity, quality, and duration of the pain, and use a pain scale or a pain assessment tool to measure the pain. The nurse would also check for any physical or behavioral signs of pain, such as grimacing, guarding, or restlessness. The nurse would document the pain assessment and report any changes or concerns to the doctor.