A visiting nurse completes an assessment of the ambulatory client in t

A visiting nurse completes an assessment of the ambulatory client in the home and determines the nursing diagnosis of risk for injury related to decreased vision. Based on this assessment, the cli-ent will benefit the most from:

1. Installing fluorescent lighting throughout the house
2. Becoming oriented to the position of the furniture and stairways
3. Maintaining complete bed rest in a hospital bed with side rails
4. Applying physical restraints

ANSWER

ANS: 2
Orienting the client to the position of furniture in the room and stairways is the best intervention to help prevent falls for the client with decreased vision. Attempts should be made to reduce glare. Light bulbs that are 60 watts or less may be increased to 75 watts to help improve visibility. The best intervention to prevent falls is to first orient the client to the surroundings. Maintaining complete bed rest is not the best option. Complete bed rest can cause other health problems re-sulting from a lack of mobility. The client should not be restrained for poor vision. Attempts should be made to help compensate for the decreased vision in order to prevent falls.