When assessing your client who has a history of falls, you should pay particular attention to which of the following? (Select all that apply.)

A. Provide a urinal and drinking water.

Explanation: While providing a urinal and drinking water is important for the client's comfort and hydration, it may not directly address the risk of falls in this situation.

B. Call for someone to bring the sign.

Explanation: Bringing a fall risk sign is a secondary measure and not as immediate as instructing the client to use the call bell. The priority is to ensure the client's safety by addressing the need for assistance promptly.

C. Instruct the client to use the call bell for help.

Explanation: Instructing the client to use the call bell for help is a crucial intervention to ensure that the client can request assistance when needed. Promptly responding to the call bell allows healthcare providers to assist the client with activities such as getting out of bed, using the bathroom, or reaching personal items without the risk of falls. Educating and encouraging clients to use the call bell empowers them to seek assistance and promotes their safety.

D. Ensure he can reach his personal items.

Explanation: Ensuring the client can reach personal items is part of providing a comfortable environment but may not prevent falls. The critical factor in fall prevention is promoting communication and the ability to request assistance in a timely manner.

A. Decreased serum albumin levels.

Explanation: Decreased serum albumin levels can be an indicator of poor nutritional status, but they are not as immediate or easily observed as unintentional weight loss.

B. Decreased vitamin D levels.

Explanation: Decreased vitamin D levels may indicate a specific nutrient deficiency but may not capture the overall nutritional status comprehensively.

C. Unintentional weight loss.

Explanation: Unintentional weight loss is a significant indicator of potential nutritional deficits and can be associated with underlying health issues. It can lead to deficiencies in essential nutrients, negatively impacting an individual's overall health and well-being. Weight loss should prompt further assessment and intervention to identify the underlying causes and address nutritional needs

D. Anorexia lasting more than 24 hours.

Explanation: Anorexia (loss of appetite) lasting more than 24 hours may contribute to inadequate nutrient intake, but it is not as direct an indicator as unintentional weight loss, which reflects changes in body composition and overall nutritional status.