An 82-year-old client with mild cognitive impairment is admitted to the medical unit. The nurse is developing a safety plan to prevent falls. Which intervention should be the nurse's highest priority?
1Install motion-sensor lighting in the bathroom and hallways
2Provide the client with a bedside commode for nighttime use
3Conduct a comprehensive fall risk assessment using a validated tool✓ 정답
4Place the client on hourly rounding schedule during daytime hours
해설
A comprehensive fall risk assessment using a validated tool is the highest priority because it provides the foundation for all other interventions by identifying specific risk factors unique to this client.
Core Nursing Explanation
This question tests the foundational principle of the nursing process, specifically the critical importance of assessment before intervention. For a patient with mild cognitive impairment (MCI) who is at risk for falls, the nurse must first gather data to understand the specific nature and level of that risk.
Key Concept Analysis: The core theme is priority-setting in nursing care planning. The Key Point! is that effective, individualized care cannot be planned without first conducting a thorough assessment. A comprehensive fall risk assessment using a tool like the Morse Fall Scale or Hendrich II Fall Risk Model systematically evaluates multiple factors (history of falls, gait, mental status, medications, toileting needs, etc.). This data-driven approach is the essential first step in Evidence-Based Practice (EBP).
Answer Rationale: Option ③ is correct because it represents the assessment phase. You must know the patient's specific risks before you can act effectively. Implementing interventions (options 1, 2, 4) without a proper assessment is like guessing—it may help, but it's not targeted, efficient, or necessarily addressing the most critical issue for this specific patient. The assessment guides which interventions are most appropriate and should be prioritized.
Distractor Analysis:
Watch out for confusion! Options ①, ②, and ④ are all excellent, evidence-based fall prevention interventions. However, they are implementations, not the foundational assessment.
- Option ① (motion-sensor lighting): A good general safety measure, but it assumes environmental lighting is a primary risk without assessing the patient's specific mobility, vision, or behavior.
- Option ② (bedside commode): Addresses a common risk factor (nocturia and rushing to the bathroom), but it is a solution implemented after assessing that toileting is a contributing factor. It may not be the top priority if the assessment reveals a greater risk from gait instability or medication side effects.
- Option ④ (hourly rounding): A proactive nursing strategy to address needs like toileting and positioning, but the frequency and timing (e.g., is nighttime rounding needed?) should be determined by the initial risk assessment.
Related Concepts: This question reinforces the ADPIE framework (Assessment, Diagnosis, Planning, Implementation, Evaluation). In priority questions, "Assess First" is a golden rule unless the scenario presents an immediate, life-threatening ABC (Airway, Breathing, Circulation) problem. For chronic or potential risks like falls, assessment is always the priority action.
Concept Summary
- Nursing Process Priority: Assessment → Diagnosis → Planning → Implementation → Evaluation (ADPIE).
- Fall Prevention: A multi-factorial issue requiring a systematic approach: Assess risk → Identify specific factors → Plan targeted interventions.
- Gerontological Nursing: Older adults, especially those with cognitive changes, are at high risk for falls due to polypharmacy, sensory deficits, gait instability, and environmental hazards.
Side-by-Side Comparison!
Action
Phase of Nursing Process
Purpose in Fall Prevention
Conduct a fall risk assessment
Assessment
To gather objective and subjective data to identify specific, individualized risk factors.
Install grab bars, provide commode
Implementation
To modify the environment or routine based on the identified risks (e.g., impaired mobility, toileting needs).
Educate patient on safe mobility
Implementation (Patient Education)
To empower the patient based on their cognitive ability and assessed knowledge deficits.
Anatomy, Physiology & Pharmacology Points
- Cognitive Impairment: Mild Cognitive Impairment (MCI) affects judgment, processing speed, and ability to recognize hazards, increasing fall risk.
- Age-Related Changes: Decreased proprioception, slower reflexes, postural hypotension, and decreased bone density (osteoporosis) make falls more likely and more dangerous.
- Polypharmacy: Common in older adults. Sedatives, hypnotics, antihypertensives, and diuretics can cause dizziness, orthostasis, and confusion, significantly increasing fall risk.
Memory Tips
- ADPIE Order: Always remember the sequence. You can't Do (Diagnose/Intervene) until you Assess.
- Acronym: For fall risk factors, think "SPACE MD": Sedatives, Postural hypotension, Altered cognition, Care environment, Elimination needs / Mobility issues, Dizziness.
- Mnemonic: "Assess Before Acting" for safety and risk management questions.
High-Frequency NCLEX Topics
The NCLEX heavily tests nursing process and priority-setting. "What should the nurse do first?" is a classic question style. Fall prevention is a Core safety topic in exams for geriatric, medical-surgical, and fundamental nursing. Expect questions that ask you to choose between a good intervention and the essential initial assessment.
Watch Out for Question Variations!
- Instead of "highest priority," the question may ask for the "first action" or "initial nursing intervention."
- The scenario could change: A patient on a new medication (e.g., diuretic), a post-operative patient, or a patient with Parkinson's disease. The principle remains: Assess the specific risk first.
- The question might list assessment findings (e.g., "unsteady gait, history of two falls at home") and then ask for the priority nursing diagnosis (e.g., Risk for Falls) or intervention (e.g., implement fall precautions per protocol).
Nursing Clinical Practice GuideClinical Scenario: You are the nurse admitting Mr. Johnson, an 82-year-old with mild cognitive impairment, to your medical unit for management of heart failure. His daughter mentions he has become "a bit wobbly" at home. Your first task is to ensure his safety.Nursing Intervention Strategy:
1Assessment (Priority Action)Immediately complete a validated fall risk assessment tool. Check his gait (get him to walk a few steps with assistance), evaluate his mental status (Is he oriented? Does he follow commands?), review his medication list for fall-risk drugs (sedatives, diuretics, antihypertensives), and ask about his toileting patterns.
2Planning & ImplementationBased on the assessment score and identified risks:
- If high risk: Initiate a fall prevention protocol. Place a fall risk alert on his chart and door. Ensure the bed is in low position, brakes are locked, and personal items are within reach.
- If toileting is a risk (per assessment): Then implement option ② (provide a bedside commode).
- If environmental hazards are noted: Then implement option ① (ensure adequate lighting, clear pathways).
- Schedule rounding: Then plan option ④, but tailor the frequency (e.g., every 2 hours at night if nocturia is a factor).
3Patient & Family EducationEducate Mr. Johnson and his daughter on the plan. Use simple instructions: "Call for help before getting up." Involve the daughter in safety measures for discharge planning.
4EvaluationReassess fall risk with each shift or if his condition changes (e.g., after new medication). Document all interventions and the patient's response.
Patient Safety and Precautions:
- Key Point! Never use restraints as a first-line fall prevention strategy. They increase agitation, injury risk, and are ethically and legally restricted.
- Ensure non-slip footwear is worn whenever the patient is out of bed.
- Communicate the fall risk plan to all members of the healthcare team during handoff reports.
Nursing Procedure & Medication Flow
1Fall Risk Assessment Procedure1. Introduce yourself and explain the purpose.
2. Use the institutional tool (e.g., Morse Fall Scale).
3. Observe gait and balance.
4. Assess cognitive status (e.g., ask day, place, situation).
5. Review medications and medical history.
6. Document the score and specific risk factors.
2Medication ImplicationsBefore administering medications like furosemide (Lasix) (a diuretic) or lorazepam (Ativan) (a sedative) to an older adult, consider timing. Administer diuretics early in the day to minimize nighttime trips to the bathroom. Assess for orthostatic hypotension before and after giving antihypertensives.
A Word from Your Senior Nurse
"On the floor, we can't implement every good idea at once—we need a plan. That plan starts with knowing your patient. A fall risk assessment isn't just a box to check; it's your clinical roadmap. It tells you if the patient is likely to fall trying to get to the bathroom at 3 AM or if they're more at risk from dizziness when they stand up. By making assessment your unwavering first step, you move from practicing 'cookbook nursing' to practicing thoughtful, patient-centered care. This mindset is what the NCLEX tests and what will make you an exceptional nurse."
Nursing Process — The systematic framework for nursing care: Assessment, Diagnosis, Planning, Implementation, Evaluation. Assessment is always the first step.
Fall Risk Assessment — A systematic evaluation using a validated tool (e.g., Morse Fall Scale) to identify a patient's specific risk factors for falling, forming the basis for a prevention plan.
Mild Cognitive Impairment — A condition involving noticeable cognitive decline greater than expected for age, but not severe enough to interfere significantly with daily life. It increases risk for safety issues like falls.
Evidence-Based Practice — The integration of best research evidence with clinical expertise and patient values to guide clinical decision-making. Using a validated fall risk tool is an EBP action.
Hourly Rounding — A proactive nursing strategy of checking on patients at regular intervals to address needs (pain, positioning, toileting) before they call, which can reduce falls.