A patient found on the floor must be assessed for injury (especially head injury on anticoagulants) before being moved and the event reported.
Before you read
Test yourself first: 5 questions
Question 1 of 5
A nurse is planning care for a client with advanced Parkinson disease who has bradykinesia and a shuffling gait. Which intervention best reduces the risk of falls?
Answer: B. Postural instability and a shuffling, festinating gait place clients with Parkinson disease at high fall risk. Removing throw rugs, ensuring adequate lighting, and providing clear pathways reduce environmental hazards. Encouraging quick position changes, dim lighting, and bed rest would each increase risk of injury or deconditioning.
Question 2 of 5
A client recovering from anesthesia is drowsy and unsteady. To prevent falls, the nurse:
Answer: B. Keep the bed low and locked, raise two side rails, place the call light within reach, assist with transfers, and instruct the client not to get up alone until cleared. Leaving them to ambulate alone is unsafe.
Question 3 of 5
A nurse is creating a fall-prevention plan for a 78-year-old admitted with new-onset confusion. Which intervention is the priority?
Answer: B. Keeping the call light within reach and frequently rounding addresses the leading remediable fall risk in confused older adults. Side rails up on all four rails is considered a restraint and can increase injury when a patient climbs over them. Sedating the patient and keeping the room dark both increase fall and delirium risk.
Question 4 of 5
A nurse is caring for a client with a subarachnoid hemorrhage from a ruptured aneurysm and aneurysm precautions are ordered. Which environment best meets these precautions?
Answer: B. Aneurysm precautions aim to prevent rebleeding by minimizing stimuli and Valsalva. A quiet, dimly lit room with limited visitors, stool softeners, and avoidance of straining reduces ICP spikes.
Question 5 of 5
Setting up seizure precautions for a client, the nurse ensures:
Answer: B. Seizure precautions: padded side rails, suction and oxygen available at the bedside, bed low, and remove hazards. Do not place objects in the mouth or restrain during a seizure.
Keep the streak going with more questions like these, each with a full rationale.
What is fall precautions?
Risk rises with advanced age, confusion, sedation, mobility problems, urinary urgency, orthostatic hypotension, and certain medications (sedatives, antihypertensives, diuretics, opioids). The nurse identifies at-risk patients with a screening tool and applies tailored interventions, with the call light, bed alarm, and a low locked bed as foundational measures.
Key points to remember
- Highest-risk patients include older adults, the confused or sedated, those with impaired mobility or gait, and patients on sedatives, diuretics, antihypertensives, or opioids.
- Orthostatic hypotension and toileting needs are common triggers; many falls happen on the way to the bathroom.
- A validated fall-risk tool (e.g., Morse) identifies patients who need precautions and visual identifiers like a colored armband or door sign.
- Keeping the bed in the lowest locked position, call light within reach, and frequently used items nearby reduces falls.
- Nonskid footwear, adequate lighting, clear pathways, and assistive devices within reach support safe mobility.
- Restraints and side rails are not first-line fall prevention; four raised side rails are considered a restraint and can increase injury.
Nursing priorities
- Screen every patient on admission and after any change in condition, and flag those at risk with a wristband and signage.
- Keep the bed low and locked, the call light and personal items within reach, and instruct the patient to call before getting up.
- Perform purposeful hourly rounding addressing toileting, pain, positioning, and possessions to anticipate needs.
- Assist with ambulation and toileting for high-risk patients, use nonskid socks, and apply a bed/chair alarm when indicated.
- Reassess orthostatic vitals and medications, and place high-risk patients near the nurses' station for closer observation.
Patient teaching
- Always use the call light and wait for help before getting up; do not try to walk to the bathroom alone.
- Sit on the edge of the bed for a moment before standing to avoid dizziness.
- Wear nonskid footwear and keep your path and glasses, walker, or cane within easy reach.
Red flags: report now
- A patient found on the floor must be assessed for injury (especially head injury on anticoagulants) before being moved and the event reported.
- Sudden weakness, dizziness, or a drop in blood pressure on standing requires assistance and reassessment before ambulating.
- Do not use four raised side rails as a fall-prevention shortcut; it is a restraint and increases entrapment/injury risk.
- Never leave a high-risk patient unattended in the bathroom or on a bedside commode.
References
Clinical references for this topic
