is a participant in the Amazon Services LLC Associates Program. These are the nursing books and resources that we recommend. Saunders comprehensive review for the NCLEX-RN examination. Medical-surgical nursing: Concepts for interprofessional collaborative care. Nursing care plans: Diagnoses, interventions, & outcomes. Nursing diagnoses handbook: An evidence-based guide to planning care. Prioritizing the removal of clutter and maintaining clear pathways helps create a safer environment and reduces the likelihood of falls.Īckley, B. Rationale: Clutter in the patient’s room can increase the risk of falls by creating obstacles or tripping hazards. Question 5: Which of the following factors should the nurse prioritize when conducting an environmental assessment to prevent falls? Reviewing the patient’s medication regimen can help identify medications that may exacerbate this condition and contribute to falls, allowing for adjustments or alternative treatment options to be considered. Rationale: Orthostatic hypotension, a drop in blood pressure upon standing, can contribute to falls. Question 4: Which of the following interventions is most effective in reducing the risk of falls related to orthostatic hypotension?ĭ) Monitoring the patient’s blood pressureĪnswer: A) Implementing a medication review Rationale: The patient’s history of falls is an essential factor to assess as it helps identify their previous fall experiences and provides insights into potential risk factors or causes, helping to determine the likelihood of future falls. Which of the following factors should the nurse prioritize in the assessment?Ĭ) The patient’s blood pressure in different positionsĪnswer: D) The patient’s history of falls Question 3: A nurse is performing a fall risk assessment for an elderly patient. Rationale: Encouraging the use of assistive devices, such as a cane or walker, can provide stability and support during mobility, reducing the risk of falls in a patient with impaired mobility. Medication review: Assess the patient’s current medications, including prescription drugs, over-the-counter medications, and supplements.ī) Ensuring proper lighting in the patient’s roomĪnswer: A) Encouraging the use of a cane or walker History of falls: Inquire about any previous falls the patient has experienced. The patient will be able to prevent a fall by means doing activities that can be done within the parameters of visual limitation and by modifying environment to adapt to current vision capacity.Patient will maintain safety by having no falls and fall-related injuries. The patient will maintain the ability to perform activities of daily living without having a fall.The patient will understand the importance of using assistive devices and extra measures for preventing falls.Unsafe environment Expected Outcomes & Goals for Fall Risk.
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