# Place the nursing actions in order after finding an anticoagulated older adult on the floor after an unwitnessed fall.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=396383&lang=en  
> language: en  
> subject: Accident/Error/Injury Prevention  
> category: SIPC

## Question

Place the nursing actions in order after finding an anticoagulated older adult on the floor after an unwitnessed fall.

Remain with the client, stop unassisted movement, call for help, and address any immediate environmental danger

Notify the responsible clinician or emergency team promptly and prepare for indicated imaging, treatment, and enhanced observation

Assess responsiveness, airway, breathing, circulation, cervical-spine risk, and obvious bleeding before moving the client

Document the objective findings and response, complete required reporting, and revise the individualized fall-prevention plan

Obtain baseline vital signs, neurologic status and Glasgow Coma Scale, glucose when indicated, pain, injuries, and the medication history

## Explanation

Stay with the client and obtain help before attempting to lift. Assess ABCs, possible cervical injury, and bleeding first, then establish neurologic and vital-sign baselines while recognizing the added intracranial-bleeding risk from apixaban. Notify the clinician or emergency team promptly for further evaluation and monitoring. Document and revise prevention after urgent care is underway.

## In-depth explanation

Correct sequence
Stay and summon help → assess before moving → establish neurologic and vital baselines → escalate for evaluation and monitoring → document and prevent recurrence.

Why this is correct
An unwitnessed fall can involve head or cervical injury. Older age and anticoagulant therapy increase the risk of occult intracranial bleeding, so a new headache requires prompt escalation even without external blood.

NCLEX decision rule
Do not lift first and assess later. Stabilize, obtain a reliable baseline, communicate the high-risk medication, and continue ordered neurologic observation.References
1AHRQ Preventing Falls in Hospitals: postfall assessment
2AHRQ Blood Thinner Safety Guide

## Clinical scenario

High-injury-risk postfall response
The client takes apixaban and reports a new headache. Do not assume that the absence of visible bleeding excludes intracranial injury. Follow the hospital's postfall and emergency-response protocol.

## Key concepts

- **Occult Bleeding** — Bleeding that is not visible externally and may first appear through symptoms or physiologic changes.
- **Glasgow Coma Scale** — A structured assessment of eye opening, verbal response, and motor response used to trend consciousness.
- **Postfall Huddle** — A timely team review of fall circumstances, injury findings, contributing factors, and prevention changes.

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