Review the client's changing fall risk during the shift and select the prevention plan that matches the new risk factors.
Trend
Choose your responses, then check the answer.
Explanation
Fall risk is dynamic. Baseline independence does not protect the client after orthostatic symptoms, sedating medication, unsteady gait, and an attempted unassisted transfer develop. The nurse should reassess and communicate the changed risk, identify the client's specific contributors, and implement a tailored plan such as assisted scheduled toileting, call-light and personal-item access, appropriate footwear, a low and locked bed, clear pathways, and medication or orthostatic review. A generic fall-risk sign alone is not an individualized plan, and physical restraints can increase injury and are not a routine first-line prevention strategy.
Trend to recognize The client's risk rises after dizziness, medication exposure, gait change, and an attempt to toilet alone. Yesterday's or admission status is no longer the correct plan.
Prevention sequence Reassess risk, identify the person's current risk factors, build a tailored plan, and carry it out consistently with the client and team.
Tailored actions Assisted scheduled toileting directly addresses urgency and unsafe transfers; a low locked bed, clear path, reachable call light, footwear, and review of dizziness and medications address additional contributors.
Why the alternatives fail A wristband or sign communicates risk but does not prevent a fall by itself. Telling the client to remain in bed without a toileting plan does not address the trigger. Routine restraints can cause harm and do not replace individualized prevention.
Source
1AHRQ Fall TIPS Patient-Centered Fall Prevention Toolkit
22026 NCLEX-RN Test Plan
Medical-surgical unitAn older adult was independent at home and is admitted for dehydration. The nurse reassesses fall risk as treatments, symptoms, and mobility change.