ATI Custom PN Basic Care and Comfort assessment
ATI Custom PN Basic Care and Comfort assessment ( 50 Questions)
As a nurse prepares an older adult client for bed on the first night of her hospital stay, the client says, “I am afraid that I may fall getting to the bathroom during the night. I tend to get a bit disoriented in new surroundings.” Which of the following actions should the nurse take?
Offer to request a prescription for an indwelling urinary catheter.Indwelling urinary catheters carry risks, including the risk of infection, and should not be used solely for the purpose of addressing the fear of falling. Catheter use should be based on medical necessity.
Keep a night light on in the client’s room.This is the most appropriate action. Keeping a night light on can help the client navigate the new surroundings more safely and reduce the risk of falls due to disorientation.
Limit the client’s fluid intake in the evening.
Limiting fluid intake, especially in the absence of a medical indication, may lead to dehydration and is not the best solution for addressing the fear of falling.
Put the side rails up and tell the client to call for assistance to the bathroom.While encouraging the client to call for assistance is important, putting all four side rails up can be considered a restraint. Restraints should be avoided whenever possible to promote mobility and independence. It's important to balance safety with maintaining the client's autonomy.
A. Offer to request a prescription for an indwelling urinary catheter.
Indwelling urinary catheters carry risks, including the risk of infection, and should not be used solely for the purpose of addressing the fear of falling. Catheter use should be based on medical necessity.
B. Keep a night light on in the client’s room.
This is the most appropriate action. Keeping a night light on can help the client navigate the new surroundings more safely and reduce the risk of falls due to disorientation.
C. Limit the client’s fluid intake in the evening.
Limiting fluid intake, especially in the absence of a medical indication, may lead to dehydration and is not the best solution for addressing the fear of falling.
D. Put the side rails up and tell the client to call for assistance to the bathroom.
While encouraging the client to call for assistance is important, putting all four side rails up can be considered a restraint. Restraints should be avoided whenever possible to promote mobility and independence. It's important to balance safety with maintaining the client's autonomy.