The nurse should encourage which of the following exercise(s) to assist with balance for a client who is at high risk for falls? (Select all that apply.

A. Use cool or tepid water: Applying cool or tepid water to the body, such as through a cool bath or damp cloth, can help reduce body temperature.

B. Avoid alcohol: Alcohol can contribute to dehydration, which increases the risk of hyperthermia. It's important to encourage the client to avoid alcoholic beverages during hot weather.

C. Minimize exertion: Exertion in high temperatures can lead to an increase in body heat. Advising the elderly client to minimize physical exertion during hot weather helps prevent overheating.

D. Wear cool clothing such as silk or polyester: Light and breathable fabrics, such as silk or polyester, promote better air circulation and help the body stay cool.

E. Drink plenty of fluids: Staying hydrated is crucial in preventing hyperthermia. Encourage the client to drink plenty of fluids, particularly water, to maintain proper hydration levels.

A. Four-length rails.

Explanation: Four-length rails fully enclose the bed and can be considered a more restrictive measure. They may be used when a restraint order is in place, but for an alert patient without such an order, less restrictive alternatives are preferred.

B. One-length rail.

Explanation: Using one-length rails can be a less restrictive alternative when a patient is at high risk for falling. The use of one side rail allows for some protection against falls without fully restraining the patient. This approach helps maintain the patient's mobility and autonomy while still providing a safety measure.

C. Two full-length rails.

Explanation: While using two full-length rails is less restrictive than four-length rails, it is still more restrictive than using only one side rail. The goal is to balance fall prevention with the patient's autonomy.

D. No side rails.

Explanation: Using no side rails may not provide adequate protection for an alert patient at high risk for falling. While avoiding restraints is essential, implementing at least one side rail is a reasonable compromise to enhance safety without fully restricting the patient's movement.