Which of the following interventions is most appropriate for a patient that gets 30 points on the Morse Fall Scale? (Select All that Apply.)

A. Place a seat alarm in the client's chair: This action is the most appropriate first step. A seat alarm can alert the nurse if the client attempts to stand or leave the chair, allowing for timely intervention while promoting the client's dignity and autonomy. This approach aims to enhance safety without the use of restraints or medications.

B. Administer lorazepam to the client: While lorazepam may help manage agitation, it should not be the first action taken. Pharmacological interventions should be considered after non-pharmacological strategies have been explored. Additionally, administering medication requires careful assessment of the client’s current state and potential side effects.

C. Apply a vest restraint on the client: Restraints should be used only as a last resort and after all other options have been considered. Applying a vest restraint can lead to increased agitation and feelings of helplessness, which may exacerbate the client’s condition. The nurse should prioritize less restrictive interventions.

D. Place the client in bed with the two side rails raised: This action can pose safety risks, as raising side rails may create a false sense of security and could lead to falls if the client attempts to get out of bed. Additionally, confining the client to bed can lead to increased confusion and agitation. It is important to provide a safe environment that encourages mobility while minimizing the risk of falls.

A. Allowing the patient to ambulate independently: This intervention is not appropriate for a patient who scores 30 points on the Morse Fall Scale, which indicates a high risk of falling. The patient should be monitored closely and assisted with ambulation to prevent falls.

B. Administering a sedative to keep the patient calm: While it may be important to keep the patient calm, using sedatives should be approached with caution, as they can increase the risk of falls and impair judgment and coordination. This intervention is not the most appropriate approach to fall prevention.

C. Placing the patient in restraints: Restraints should be used only as a last resort and only when necessary to prevent harm to the patient or others. Using restraints can lead to physical and psychological harm and should not be the primary intervention for fall prevention.

D. Implementing a fall prevention protocol: This is the most appropriate intervention for a patient with a high risk of falling. A fall prevention protocol may include measures such as ensuring a clear path, using assistive devices, and conducting regular assessments of the patient's mobility and safety.

E. Educating the patient on using the call light system: This intervention is important for ensuring the patient feels safe and can call for assistance when needed. Educating the patient on the call light system promotes communication and can help prevent falls by encouraging the patient to seek help when they need to move or ambulate.