A nurse is teaching a group of older adults about fall prevention. Which strategy is most effective for this audience?

Choice A rationale
The client properly using a cane and demonstrating a steady gait indicates that the client has good mobility and balance. This is not likely to contribute to falls. Proper use of assistive devices like canes can actually help prevent falls by providing additional support and stability.
Choice B rationale
The client takes a sleeping pill. Many sleeping pills, especially those in the benzodiazepine class, can cause drowsiness, dizziness, and impaired coordination, which significantly increase the risk of falls. These medications can affect the central nervous system, leading to decreased alertness and slower reaction times, making it more likely for the client to fall.
Choice C rationale
The client uses a raised toilet seat. Raised toilet seats are designed to make it easier for individuals to sit down and stand up from the toilet, reducing the risk of falls in the bathroom. This adaptation is generally considered a fall prevention measure rather than a risk factor.
Choice D rationale
The client wears non-skid shoes. Non-skid shoes are designed to provide better traction and reduce the likelihood of slipping. Wearing such shoes is a preventive measure against falls, not a contributing factor.

Choice A rationale
The statement “The vital signs are stable” is incorrect for the fifth step of the SBAR communication tool. The fifth step in SBAR is the Recommendation step, where the nurse provides a recommendation or request for what action should be taken next. Stating that the vital signs are stable does not provide a clear recommendation or action plan for the provider to follow.
Choice B rationale
The statement “The client has a history of high blood pressure” is incorrect for the fifth step of the SBAR communication tool. This information belongs in the Background step, where the nurse provides relevant clinical background information about the patient’s condition. The Recommendation step should focus on what action the nurse recommends based on the assessment.
Choice C rationale
The statement “The client should be seen by a neurologist” is correct for the fifth step of the SBAR communication tool. In the Recommendation step, the nurse provides a clear and specific recommendation for what action should be taken next. Recommending that the client be seen by a neurologist is an appropriate and actionable recommendation based on the nurse’s assessment.
Choice D rationale
The statement “The client is experiencing severe headaches” is incorrect for the fifth step of the SBAR communication tool. This information belongs in the Assessment step, where the nurse provides an analysis of the patient’s current condition. The Recommendation step should focus on what action the nurse recommends based on the assessment.