The nurse is completing a fall risk assessment for a client. Which factor places the client at the highest risk for falls?

Age over 65 years.

Use of anticoagulant medications.

History of previous falls.

Presence of sensory deficits.

Answer and Explanation

The Correct Answer is C

Answer: c. History of previous falls. Explanation: A history of previous falls is a significant risk factor for future falls. Clients who have fallen before are more likely to fall again, making it a high-risk factor to consider in fall prevention strategies.

Incorrect choices: a. Age over 65 years is a general risk factor for falls but does not provide as much predictive value as a history of previous falls. b. Use of anticoagulant medications increases the risk of bleeding but does not necessarily indicate a higher risk for falls. d. Presence of sensory deficits, such as visual or auditory impairments, can contribute to fall risk but may not be the highest-risk factor compared to a history of previous falls.

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Correct Answer is A

Explanation

Answer: a. "I will make sure to wear my eyeglasses all the time." Explanation: The statement "I will make sure to wear my eyeglasses all the time" indicates a need for further education on fall prevention. While wearing eyeglasses can improve vision, it is not adirect fall prevention measure. It is important for the client to address other risk factors such as environmental hazards, balance, and mobility.

Incorrect choices: b. "I will use the handrails when going up and down the stairs." This statement demonstrates an understanding of using handrails for support and stability while navigating stairs, which is an appropriate fall prevention measure. c. "I will ask for help when I need to use the bathroom at night." This statement reflects the client's awareness of the need to seek assistance when necessary, reducing the risk of falls during nighttime bathroom visits. d. "I will keep my room well-lit during the day and night." This statement indicates an understanding of the importance of adequate lighting to enhance visibility and prevent falls in the client's room.

A. Providing the client with a walker for ambulation. B. Encouraging the client to perform regular exercise. C. Placing the client in restraints to prevent wandering. D. Administering sedative medications to promote rest.

Correct Answer is A

No explanation

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The nurse is completing a fall risk assessment for a client. Which factor places the client at the highest risk for falls?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is A

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