# A nurse is performing fall-risk assessment on a 78-year-old client admitted for community-acquired pneumonia. The client uses a single-point cane at home, wears bifocal eyeglasses, takes lorazepam 0.5 mg at bedtime, and reports two falls in the past year. Vital signs and orthostatic readings are stable. Which actions are appropriate at this point? Select all that apply.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=368184&lang=en  
> language: en  
> subject: System-Specific Assessments  
> category: ROR

## Question

A nurse is performing fall-risk assessment on a 78-year-old client admitted for community-acquired pneumonia. The client uses a single-point cane at home, wears bifocal eyeglasses, takes lorazepam 0.5 mg at bedtime, and reports two falls in the past year. Vital signs and orthostatic readings are stable. Which actions are appropriate at this point? Select all that apply.

1

Apply a yellow fall-risk wristband and post the fall-risk sign at the bedside per facility protocol

2

Place the call light, water, and personal items within reach and educate the client to call before getting up

3

Order continuous 1:1 sitter for the entire shift without consulting the prescriber or interdisciplinary team

4

Discontinue the bifocal eyeglasses to prevent depth-perception fall risk during hospitalization

5

Apply 4-point soft restraints because of the bedtime lorazepam and the prior fall history

6

Restrict the client to bed rest with bedpan use only for the duration of admission

## Explanation

Fall-risk identification (Morse, Hendrich II, Tinetti) and standard fall precautions are the first line. Required actions: (1) visible fall-risk identification (yellow band, signage) per most facilities — alerts all team members; (2) call-light access plus environmental setup with proactive education — empowers the client to ask for help before mobilizing. Four-point restraints (option 5) are inappropriate without documented imminent harm and a least-restrictive trial — and they paradoxically increase fall and injury risk. Removing bifocals (option 4) impairs vision and increases fall risk; counsel on careful stair and curb navigation instead. Strict bed rest (option 6) accelerates deconditioning and delirium — early mobility is preferred. Continuous 1:1 sitter (option 3) requires interdisciplinary planning and is rarely first-line; it is reserved for documented continued risk despite standard precautions.

## In-depth explanation

Fall Risk in Hospitalized Older Adults
Multiple risk factors: prior falls (strongest predictor), benzodiazepines, vision (bifocals on stairs), gait and cane use, polypharmacy.

Standard Fall Precautions Bundle
1. Risk score (Morse / Hendrich II / Tinetti)
2. Visual alerts: yellow band, signage
3. Call light and items in reach
4. Bed in low position, brakes locked
5. Non-skid footwear
6. Toileting rounds every 2 hours
7. Medication review (especially benzo, opioid, antihypertensive)
8. Orthostatic checks

Wrong Answers
3: Restraints increase, not decrease, fall injury.
4: Glasses help vision; counsel on use, do not remove.
5: Bed rest equals deconditioning plus delirium.
6: 1:1 sitter requires interdisciplinary planning.

NCSBN Theme
ROR — Reduction of risk potential.

## Clinical scenario

Scenario
78-year-old, community-acquired pneumonia admission.

Fall Risk Profile
- Single-point cane at home
- Bifocal eyeglasses
- Lorazepam 0.5 mg HS (benzodiazepine)
- 2 falls in past year
- Vitals and orthostatic readings stable

Action Plan
- Standard fall precautions bundle
- Visual alerts
- Call light access plus education
- Toileting rounds
- Avoid bed rest, restraints, and lone 1:1 without team review

## Key concepts

- **Fall risk assessment tools** — Validated tools to quantify hospital fall risk: Morse Fall Scale (history of fall, secondary diagnosis, ambulatory aid, IV / heparin lock, gait, mental status), Hendrich II (confusion, depression, altered elimination, dizziness, gender, antiepileptic, benzo, get-up-and-go), Tinetti (gait and balance). A score above threshold triggers the standard fall precautions bundle.
- **Standard fall precautions** — Universal interventions for at-risk patients: visual alerts (yellow band, sign), call light and personal items within reach, bed in lowest position with brakes locked, non-skid footwear, scheduled toileting rounds every 2 hours, medication review for fall-promoting drugs, orthostatic monitoring, patient and family education. Restraints are NOT part of standard precautions and they increase injury risk.
- **Restraint-free fall management** — Evidence shows physical restraints (4-point, Posey) increase rather than decrease fall injury and contribute to deconditioning, delirium, and pressure injuries. Alternatives: bed alarms, low beds, hourly rounding, family at bedside, sitters when justified, environmental modifications (clear pathway, lighting), and medication optimization. Restraints are reserved for documented imminent harm with failed less-restrictive trials.

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