An 85-year-old client with diabetes, heart disease, and renal insufficiency is admitted. What action should the nurse take to prevent falls by this particular client?
A. Provide assistance to the client in getting out of the bed or chair.
B. Place the client in restraints to prevent movement without assistance.
C. Maintain the client on complete bedrest with the siderails up at all times.
D. Request that a family member remain with the client at all times to assist in am-bulation.
A
Advanced age, multiple illnesses, particularly those that result in alterations in sensation, such as diabetes, predispose this client to falls. The nurse should provide assistance to the client with transfer and ambulation to prevent falls. The client should not be restrained or maintained on bedrest without adequate indication. Although family members are encouraged to visit, their presence around the clock is not necessary at this point.
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