# An older adult is hospitalized after a near fall. For each cue or intervention, select the best classification.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=396165&lang=en  
> language: en  
> subject: Accident/Error/Injury Prevention  
> category: SIPC

## Question

An older adult is hospitalized after a near fall. For each cue or intervention, select the best classification.

|  | Individual fall-risk cue | Tailored prevention intervention | Reassessment or escalation trigger |
| --- | --- | --- | --- |
| Dizziness begins after standing following a recent antihypertensive dose increase |  |  |  |
| Urinary urgency, lower-extremity weakness, and unfamiliarity with the walker occur together |  |  |  |
| Schedule assisted toileting at the client’s high-risk times and keep the call light and walker within reach |  |  |  |
| Request medication review and practice supervised transfers and walker use with the client |  |  |  |
| Repeated symptomatic blood-pressure drops occur despite sitting first and rising with assistance |  |  |  |
| A near fall is followed by new unilateral weakness, confusion, syncope, or suspected injury |  |  |  |

## Explanation

Fall prevention is individualized. Orthostatic symptoms, urgency, weakness, unfamiliar equipment, cognition, and high-risk medications are actionable cues. Tailored interventions include assisted toileting, safe mobility practice, accessible equipment, and medication review. Persistent orthostatic hypotension, syncope, new neurologic findings, or injury after a near fall requires clinical reassessment rather than simply adding an alarm.

## In-depth explanation

Correct Answer
Two rows identify modifiable risk, two are matched interventions, and two trigger further diagnostic or injury assessment.

Why It Fits
The item links the reason a client may fall to an intervention and distinguishes prevention from evaluation of a new medical problem.

Clinical Picture
Alarms can alert staff but do not correct dizziness, urgency, weakness, or unfamiliar equipment. Medication and orthostatic review may reveal a treatable cause.

Memory Link
Name the risk, match the intervention, reassess the change.

NCLEX Rule
A risk score or alarm is not a prevention plan by itself.

Why the Alternatives Fail
Universal restrictions can reduce mobility without treating the cause. New syncope or neurologic change needs evaluation, not only fall precautions.

Sources
1AHRQ Preventing Falls in Hospitals Toolkit
22026 NCLEX-RN Test Plan

## Clinical scenario

The client has new dizziness when standing after medication changes, urinary urgency, lower-extremity weakness, and an unfamiliar walker. The nurse links each individual risk to a specific intervention and watches for findings that require further evaluation.

## Key concepts

- **Orthostatic hypotension** — A clinically important blood-pressure decrease on standing that can cause dizziness, weakness, or syncope.
- **Tailored fall prevention** — Interventions selected to address the particular risks identified for one client.

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