The nurse is developing a plan of care for a client who is at risk for falls. Which interventions would be appropriate for the nurse to include in the plan of care?
Select all that apply.
A) Apply physical restraints if the client gets out of bed.
B) Assess the client's vision and make sure he is utilizing any prescribed eyewear.
C) Utilize side rails on client beds.
D) Keep frequently used items within easy reach.
Answer: B, C, D
Assessing the client's vision and making sure he is utilizing any prescribed eyewear is an appropriate action. Poor and blurry vision increases the client's risk of falling. Utilizing side rails on the client bed to prevent falls while the client is sleeping is an appropriate intervention. Furthermore, it is appropriate to keep frequently used items within easy reach in an effort to prevent falls. It is not appropriate for the nurse to apply physical restraints if client gets out of bed. The nurse could include in the plan of care to apply physical restraints only when absolutely necessary for the client's safety and only by physician's order.
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