QuestionAugust 12, 2025

The nurse is caring for a confused older adult client who is a fall risk and keeps attempting to get out of bed to go to the bathroom. Which of the fallowing actions should the nurse take? 1. Decrease stimulation by turning off lights. 2. Give the client some magazines for reading 3. Insert an indwelling urinary catheter to limit bathroom trips 4. Administer diphenhydramine at night to help the client sleep.

The nurse is caring for a confused older adult client who is a fall risk and keeps attempting to get out of bed to go to the bathroom. Which of the fallowing actions should the nurse take? 1. Decrease stimulation by turning off lights. 2. Give the client some magazines for reading 3. Insert an indwelling urinary catheter to limit bathroom trips 4. Administer diphenhydramine at night to help the client sleep.
The nurse is caring for a confused older adult client who is a fall risk and keeps attempting to get out
of bed to go to the bathroom.
Which of the fallowing actions should the nurse take?
1. Decrease stimulation by turning off lights.
2. Give the client some magazines for reading
3. Insert an indwelling urinary catheter to limit bathroom trips
4. Administer diphenhydramine at night to help the client sleep.

Solution
4.5(226 votes)

Answer

None of the provided options are ideal; focus on frequent toileting assistance and monitoring instead. Explanation 1. Evaluate the options Consider safety and ethical implications. Options 1 and 2 do not address fall risk directly. Option 3 is invasive and should be avoided unless medically necessary. Option 4 involves medication that may have side effects, especially in older adults. 2. Choose the safest intervention The nurse should prioritize non-invasive methods to ensure safety and comfort. Reducing stimulation (Option 1) can help calm the client but does not prevent falls. Providing magazines (Option 2) might distract but doesn't address the need for bathroom trips. Inserting a catheter (Option 3) is not appropriate without medical necessity. Administering diphenhydramine (Option 4) can cause confusion and increase fall risk due to sedation. 3. Implement fall prevention strategies Use non-invasive measures such as frequent toileting assistance, bed alarms, or having the client in a visible area for monitoring.

Explanation

1. Evaluate the options<br /> Consider safety and ethical implications. Options 1 and 2 do not address fall risk directly. Option 3 is invasive and should be avoided unless medically necessary. Option 4 involves medication that may have side effects, especially in older adults.<br /><br />2. Choose the safest intervention<br /> The nurse should prioritize non-invasive methods to ensure safety and comfort. Reducing stimulation (Option 1) can help calm the client but does not prevent falls. Providing magazines (Option 2) might distract but doesn't address the need for bathroom trips. Inserting a catheter (Option 3) is not appropriate without medical necessity. Administering diphenhydramine (Option 4) can cause confusion and increase fall risk due to sedation.<br /><br />3. Implement fall prevention strategies<br /> Use non-invasive measures such as frequent toileting assistance, bed alarms, or having the client in a visible area for monitoring.
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