Why option 3 requires further teaching
The wife’s statement about raising
all side rails at night reflects a common but unsafe assumption: that a physical barrier will reliably keep a confused older adult in bed. In reality,
using side rails to prevent voluntary exit functions as a restraint and does not reliably prevent falls. A person with early dementia may attempt to climb over the rails, which can result in a fall from a greater height, or may become trapped between the rail and the mattress, causing injury or entrapment-related asphyxia. Because the grandfather has both
type 2 diabetes with persistent hyperglycemia and
early dementia, he is at increased risk for nighttime confusion, nocturia, and unsteady mobility—making full rail elevation especially hazardous.
Watch out! In nursing licensure exams, any intervention that restricts a patient’s freedom of movement for the purpose of preventing falls—such as raising all four side rails—is classified as a
restraint and requires a provider order, ongoing assessment, and documentation. It is not a first-line fall prevention strategy.
Why the other statements are correct
Option 1: Night-light along the bathroom path. Older adults with dementia and diabetes frequently wake at night to urinate. A dimly lit stairway and loose rugs were already identified hazards in the home.
Improving lighting along the route to the bathroom reduces fall risk by enhancing visual orientation and depth perception, which are often impaired in older adults and further compromised by cognitive decline.
Option 2: Nonskid slippers. Footwear with slip-resistant soles directly addresses traction on smooth or loose surfaces. In the context of this home—which has loose rugs—nonskid footwear is a targeted, evidence-aligned environmental modification that reduces the likelihood of slipping during transfers and ambulation.
Option 4: Sitting on the edge of the bed before standing. This addresses
orthostatic hypotension, a common concern in older adults with diabetes, especially if autonomic dysfunction or dehydration is present.
Pausing in a seated position before standing allows blood pressure to adjust and reduces dizziness-related falls. This is a standard, safe mobility technique that does not restrict the patient.
Clinical reasoning for the PNLE/NCLEX
The question tests whether the examinee can distinguish
environmental safety measures from
restraint use. The grandfather’s fall risk is multifactorial: prior fall within the past month, dementia, diabetes with poor glycemic control, home hazards, and a borrowed hospital-type bed. The nurse’s teaching should emphasize
mobility support, environmental modification, and safe transfer techniques—not containment.
| Intervention | Fall prevention mechanism | Restraint concern |
|---|
| Night-light to bathroom | Improves visual cues and orientation at night | None |
| Nonskid slippers | Increases traction on loose or smooth surfaces | None |
| Sit at edge of bed before standing | Allows BP adjustment; reduces orthostatic dizziness | None |
| Raise all side rails at night | Intended to prevent exit but may cause climbing or entrapment | Yes—acts as a restraint |
Key point! If a confused patient is at high risk for nighttime falls, safer alternatives include lowering the bed to the lowest position, placing the mattress on the floor if appropriate, using a bed alarm, or increasing supervision—not raising all side rails.