A nurse is reviewing a fall risk assessment for a client. Which of the following findings places the client at risk for a fall? Select all that apply,

A) Assessment:
Assessment involves gathering and analyzing data about the client’s health status and needs. While gathering information from the social worker and physical therapist may be part of the assessment process, the actual collaborative work in preparing the discharge plan is more aligned with the planning phase of the nursing process.

B) Planning:
Planning is the correct answer because it involves formulating goals, interventions, and expected outcomes for the client’s care, including discharge projections. In this case, the nurse, social worker, and physical therapist are working together to develop a comprehensive discharge plan tailored to the client’s needs, which is a key part of the planning phase.

C) Evaluation:
Evaluation occurs after interventions are implemented to assess whether the goals have been met and the outcomes achieved. Since the nurse is still in the process of preparing the discharge plan, evaluation has not yet occurred.

D) Analysis:
Analysis is the process of interpreting assessment data to identify problems or needs. While analysis is part of the assessment phase, it does not describe the collaborative action of creating a discharge plan, which is clearly a planning task.

A. Electrical cord on floor over a walkway:
An electrical cord on the floor in a walkway poses a significant tripping hazard. Clients may not notice the cord or may have difficulty stepping over it, increasing the risk of falls, particularly for individuals with impaired mobility or vision.

B. Demonstrates correct use of cane to ambulate:
Proper use of a cane improves balance and stability, reducing fall risk rather than contributing to it. Clients who demonstrate correct usage are actively minimizing their likelihood of falling.

C. Grab bar in the bathroom:
Grab bars provide added support and stability, particularly in areas prone to slips, such as bathrooms. Their presence is a preventive measure rather than a fall risk.

D. Diagnosis of Macular degeneration:
Macular degeneration impairs central vision, which can lead to difficulties in detecting obstacles and maintaining balance, increasing the client’s susceptibility to falls.

E. Throw rugs in kitchen:
Throw rugs are a well-documented fall hazard because they can slip, bunch up, or create uneven surfaces. They are particularly risky for older adults and those with mobility impairments.