The nurse admits an 80-year-old client with an altered level of consciousness and left-sided weakness following a recent stroke. The client is dehydrated from multiple episodes of diarrhea. Which interventions should the nurse implement to prevent falls? Select all that apply. A)Apply color-coded, nonslip socks to the client's feet B)Move the client to a room closer to the nurses' station C)Place a bedside commode to the right of the client D)Raise all bed rails before leaving the room E)Use a bed alarm to alert staff when the client gets up

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11ecbb05_cb51_d0bf_b433_e352cd40e2b7_MD0009_00 The client with right-brain damage following a stroke often experiences left-sided weakness, spatial-perceptual deficits, and impulsiveness, making this client at high risk for falls. Other factors that increase fall risk for older adults include: Unfamiliar surroundings Unsteady gait, decreased strength and coordination Altered mental status Orthostatic hypotension (related to dehydration) Bowel/bladder urgency and/or frequency Application of color-coded, nonslip socks helps prevent a client from slipping and alerts staff to a client's increased risk for falls (Option A). Placing a commode by the right (stronger) side of the bed decreases the number of steps and time needed to get to a toilet (Option C). It also decreases the chance of tripping on equipment (eg, IV pump, tubing). Moving the client to a room close to the nurses' station allows frequent observation and a faster response time to calls for assistance (Option B). A bed alarm alerts staff when the client attempts to get out of bed, which allows for prompt response (Option E). (Option D) Raising all bed rails may be constituted as an unlawful use of restraint. Clients with altered mental status may also attempt to climb the side rails and sustain a fall injury. Educational objective: Many falls are associated with bathroom urgency/frequency. Fall risk precautions include placing the client in a room near the nurses' station, placing a bedside commode by the client's stronger side, applying nonslip socks, and using a bed alarm.

The Nurse Admits an 80-Year-Old Client with an Altered Level