The nurse is caring for an older adult client who is confused and has a high risk for falls. The client is incontinent of urine and frequently attempts to get out of bed unassisted to use the restroom. Which nursing interventions are appropriate when caring for this client? Select all that apply.

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11ecbb05_cb69_777f_b433_d9092c57b41f_MD0009_00 Falls can occur with any client; however, advanced age, incontinence, confusion, and presence of lines, tubes, and drains increase the risk for falls and injury. Interventions to reduce falls in high-risk clients include: Hourly rounding (eg, assessing pain, offering toileting and nutrition) (Option B) Moving the client to a room close to the nurses' station (Option D) Activating bed alarms to alert staff if the client gets out of bed unassisted (Option A) Asking family members or visitors to stay at the bedside with the client (Option C) Lines, tubes, and drains (eg, indwelling urinary catheter, IV tubing) tether (ie, tie) the client to the bed or equipment and limit mobility, increasing fall risk. In addition, indwelling urinary catheters increase risk for infection and should be used only when clinically indicated (eg, strict hourly output, critical illness), not for the nurse's convenience (eg, clients requiring frequent toileting or incontinence care). The nurse can reduce urinary urgency and incontinence episodes by offering clients toileting with hourly rounding. (Option E) Raising all side rails is considered a physical restraint and is associated with more severe fall injuries from clients attempting to climb over the side rails. Educational objective: Interventions to reduce falls in high-risk clients include hourly rounding, moving the client to a room close to the nurses' station, and using bed alarms. Lines, tubes, drains (eg, indwelling urinary catheters), and restraints (eg, all side rails raised) increase fall risk and should be used only when clinically indicated.

The Nurse Is Caring for an Older Adult Client Who