# A 76-year-old client visits the primary care clinic for an annual wellness exam. The client reports falling once in the past 6 months and feels unsteady when standing. According to the CDC STEADI initiative, which intervention should the nurse prioritize?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=363451&lang=en  
> language: en  
> subject: Health Screening  
> category: HPM

## Question

A 76-year-old client visits the primary care clinic for an annual wellness exam. The client reports falling once in the past 6 months and feels unsteady when standing. According to the CDC STEADI initiative, which intervention should the nurse prioritize?

## Option

1. Order a hip x-ray to rule out a fracture from the fall the client reported six months ago
2. Refer the client to an audiologist for a hearing assessment as part of fall prevention
3. Conduct a Timed Up and Go (TUG) test and complete a comprehensive fall risk assessment **✔ Correct answer**
4. Recommend the client begin a daily 30-minute walking program to reduce fall risk

**Correct answer: 3**

## Explanation

The CDC STEADI initiative (Stopping Elderly Accidents, Deaths, and Injuries) follows a Screen-Assess-Intervene workflow. The client has positive screening (one fall in 12 months and unsteadiness), so the next step is structured assessment, including the Timed Up and Go (TUG) test. A TUG result of 12 seconds or more indicates increased fall risk and triggers the intervention bundle (medication review, vitamin D, balance and strength exercise, home safety, vision and footwear). A hip x-ray is reactive imaging, aerobic exercise alone misses balance training, and hearing evaluation is a downstream intervention only after assessment.

## In-depth explanation

Clinical Judgment
STEADI flow: Screen → Assess → Intervene. Positive screen here = 1 fall + unsteadiness. Next is structured assessment with TUG, 30-second chair stand, and 4-stage balance test. TUG ≥12 seconds = increased fall risk.

Memory Tip
STEADI: Screen → Assess (TUG ≥12s) → Intervene (meds, vit D, exercise, home safety)

KR vs US
STEADI is a CDC framework but the assessment tools (TUG, chair stand) are global. Korean Geriatrics Society fall guideline uses the same tests; community senior centers and tertiary geriatric clinics in Korea have adopted multifactorial fall risk assessment.

## Clinical scenario

Clinical Practice Guide
CDC STEADI multifactorial assessment for older adults with positive screen:
- Timed Up and Go: rise from chair, walk 3 m, return, sit. ≥12 seconds = high risk.
- 30-second chair stand: number of stands without using arms; sex- and age-adjusted norms.
- 4-stage balance: progressive standing positions; failure on tandem or single-leg = high risk.
- Postural BP, vision, footwear, home hazards, medication review (focus on benzodiazepines, opioids, anticholinergics).
- Recommend vitamin D 800-1000 IU daily, supervised exercise (Tai Chi, Otago).

Caution
Two or more falls in 12 months OR a fall with injury warrants immediate physician referral for a comprehensive geriatric assessment.

## Key concepts

- **STEADI** — CDC initiative Stopping Elderly Accidents, Deaths, and Injuries. Three-step framework: Screen with three key questions, Assess high-risk clients with validated tools, Intervene with evidence-based multifactorial actions. Free toolkit available at cdc.gov/steadi.
- **Timed Up and Go (TUG)** — Standardized mobility test: client rises from a chair, walks 3 meters, turns, returns, and sits. Cut-off ≥12 seconds = increased fall risk. Sensitive screening tool for community-dwelling older adults.
- **Multifactorial intervention** — Bundle of evidence-based fall prevention measures: medication review (deprescribe sedatives, anticholinergics, polypharmacy), vitamin D, balance and strength training, home hazard reduction, vision and footwear correction, postural blood pressure management.

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