Which items are appropriate for the nurse to include when ...

[chandani]

Which items are appropriate for the nurse to include when assessing a client for falls? Select all that apply.
 
  1. Reviewing for a history of falls before admission
  2. Talking with family about concerns
  3. Assessing the overall physical condition
  4. Assessing medication lists
  5. Assessing mental status

Question 2

The nurse is instructing the unlicensed assistive personnel (UAP) on fall prevention for the clients. Which statement made by the UAP warrants further instruction?
 
  1. I will ensure that the call light is within reach of the client.
  2. I will make sure to have at least one side rail up at all times.
  3. I don't have to worry about the clients who are bedridden, as they are moved by the staff.
  4. I will make sure that the bed is in the lowest position prior to leaving the room.

[Galvarado142]

Answer to Question 1

Correct Answer: 1,3,4,5

It is important for the nurse to review the client's medical record for any history of falls along with assessing the client's overall condition, medications, and mental status. All are important to determine the client's risk for falls. Talking to the family is important, but unless the family is staying with the client it is not warranted at this time.

Answer to Question 2

Correct Answer: 3

The statement indicating not having to worry about clients who are bedridden because they are moved by staff is not correct as clients who are bedridden are more prone to falls due to the loss of independence. All the other statements indicate an appropriate understanding by the UAP on fall prevention strategies for the client.