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Placing a sign on the client's room door indicating fall risk is a helpful visual reminder, but it does not actively prevent falls

Providing a nonskid mat on the floor beside the client's bed can reduce the risk of slipping but does not address other factors that contribute to falls

Ensuring the client has adequate lighting in the room is important for preventing falls, but it is not the most critical intervention. The client's ability to seek assistance when needed is more crucial.

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.

Use of anticoagulant medications increases the risk of bleeding but does not necessarily indicate a higher risk for falls

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.

Providing a bedside commode for toileting needs is important for promoting safe toileting, but it does not address the overall risk of falls.

Placing the client in a private room near the nurses' station may enhance surveillance, but it does not actively prevent falls

Educating the client on proper use of assistive devices is essential, but it is not the most critical intervention for fall prevention in the medical-surgical unit setting.

Using bed rails to restrict the client's movement is not recommended as it can increase the risk of entrapment or injury. Bed rails should be used judiciously and with caution.

Providing the client with nonskid footwear is important for promoting stability and preventing slips and falls, but it is not the most crucial intervention in this scenario

Administering sedative medications at bedtime increases the risk of falls by affecting the client's balance and alertness. Sedatives should be used sparingly and only when necessary.

. Documenting the fall incident in the client's medical record is an essential step but should follow the immediate implementation of fall prevention interventions

Conducting a comprehensive fall risk assessment is important, but it should be done as part of the ongoing care and assessment rather than immediately after a fall

Reporting the fall to the unit manager is necessary for organizational reporting purposes, but it does not directly address the client's immediate safety needs.

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.

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

"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.

Implementing a toileting schedule for the client is important but may not directly address the client's specific fall risk.

Assessing the client's orthostatic blood pressure is essential for assessing orthostatic hypotension but may not be the most appropriate intervention for addressing fall risk in this scenario.

Providing the client with a bed alarm system can help alert the nursing staff when the client is attempting to leave the bed, but it does not directly address the client's balance and stability needs.

Providing the client with nonskid footwear is important for promoting stability and preventing slips and falls but may not address all potential fall risks

Educating the client on the correct use of handrails is essential, but it may not be the most critical intervention compared to removing environmental hazards

Assisting the client with toileting and ambulation is important, but it focuses on direct assistance rather than eliminating hazards from the environment.

"I will make sure to rush to answer thephone." This statement demonstrates a misunderstanding of the importance of prioritizing safety over rushing to answer the phone, which may increase the risk of falls.

I will keep my medication bottles on the kitchen counter." This statement suggests a potential hazard of leaving medication bottles on the counter, which can increase the risk of falls due to clutter and potential spills.

I will wear socks with a smooth sole for better comfort." This statement indicates a lack of understanding of the importance of wearing nonskid footwear to maintain traction and prevent slips and falls. Smooth-soled socks may increase the risk of slipping on smooth surfaces.