An older client is observed having difficulty moving from a sitting to standing position, and has an unsteady gait. What should the nurse assess in this client to promote home safety?
1. Presence of grab bars in the bathroom
2. Absence of scatter rugs on the floors
3. Correct use of cane to ambulate
4. Ability to stand in place for a minute before ambulating
5. Alcohol use with prescribed medications
Correct Answer: 1, 2, 3
Rationale 1: For home safety, it would be beneficial for the client with difficulty moving from a sitting to standing position to have grab bars in the bathroom.
Rationale 2: For home safety, it would be beneficial for the client with an unsteady gait not to have scatter rugs on the floor.
Rationale 3: For home safety, it would be beneficial for the client with an unsteady gait to be able to use a cane correctly.
Rationale 4: The ability to stand in place for a minute before ambulating would be applicable if the client were demonstrating signs of orthostatic hypotension.
Rationale 5: The use of alcohol with prescribed medications would be beneficial if the client were prescribed sedatives or hypnotics.
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