NCLEX Practice Test

What interventions are appropriate to promote safety for an older adult client with advanced dementia, confusion, and a history of falls? Select all that apply.

1. Activate the bed alarm before leaving the room

2. Keep the lights dim to create a calm environment

3. Place a bedside commode next to the bed

4. Place the client in a room close to the nurses' station

5. Request a prescription for a vest or belt restraint

The correct answer is: Activate the bed alarm before leaving the room

Placing a bedside commode next to the bed and keeping the lights dim may actually increase the risk of falls for an older adult with advanced dementia and confusion as it may be difficult for them to navigate in a dimly lit environment and to recognize the commode as a toilet. Additionally, restraining an older adult with dementia is not recommended as it can cause further confusion and agitation. Requesting a prescription for a vest or belt restraint should also be avoided due to the potential for physical and psychological harm. Placing the client in a room close to the nurses' station may not be feasible in all healthcare settings and may not necessarily prevent falls. Activating the bed alarm before leaving the room would be the most appropriate and least restrictive intervention to promote safety for an older adult with advanced dementia, confusion, and a history of falls as it alerts healthcare staff if the client attempts to get out of bed.