Mr Olsen, age 75 years, lives in a nursing home and diagnosed with mild dementia. Occasionally he attempts to get out of bed during the night and is a risk tor falls. What nursing intervention should the practical nurse use to ensure his safety?

Reasoning: Choice A reason: Restricting fluids after 1800H is generally inappropriate and can lead to dehydration or electrolyte imbalances in the elderly. While it might reduce nocturnal voiding, it does not address the underlying cognitive impairment causing the patient to wander and may actually increase confusion due to physiological stress. Choice B reason: Placing the bed in the lowest position is a primary non-pharmacological fall-prevention strategy. For a patient with dementia who may forget they cannot walk safely, minimizing the distance to the floor reduces the impact of a fall and promotes a "restraint-free" environment, which is the current gold standard in geriatric care. Choice C reason: Using all 4 side rails is often considered a form of physical restraint. In patients with dementia, side rails can actually increase the risk of serious injury, as the patient may attempt to climb over them, falling from a much greater height than if the bed were simply lowered. Choice D reason: Restraints should never be used as a first-line intervention or on a PRN (as needed) basis for fall prevention. Physical restraints can increase agitation in patients with dementia and lead to complications such as pressure ulcers, decreased muscle tone, and increased risk of strangulation or entrapment.