# For each proposed intervention for a hospitalized client at high risk for falling, identify whether it is individualized and appropriate or needs correction.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=563779&lang=en  
> language: en  
> subject: Accident/Error/Injury Prevention  
> category: SIPC

## Question

For each proposed intervention for a hospitalized client at high risk for falling, identify whether it is individualized and appropriate or needs correction.

|  | Individualized and appropriate | Needs correction |
| --- | --- | --- |
| Agree with the client on supervised toileting times and keep the call light and urinal within reach. |  |  |
| Raise all four side rails and tell the client to climb over them if help is delayed. |  |  |
| Assess lying and standing symptoms, teach slow position changes, and remain nearby during ambulation. |  |  |
| Remove the client's cane and require bed rest for the entire admission regardless of current function. |  |  |
| Place the agreed risk factors and interventions where the client, family, and team can review them. |  |  |
| Give a sedative each night solely to prevent the confused client from attempting to stand. |  |  |

## Explanation

Effective fall prevention begins with identifying the client's specific risks, then matching interventions to those risks and carrying them out consistently. This client needs supervised mobility, slow position changes, accessible toileting, appropriate assistive devices, environmental safety, and a plan visible to the whole team. The client and family should participate so the plan supports both safety and function. Restraints, four raised side rails, routine sedation, or a generic alarm without addressing causes can increase injury, immobility, or confusion.

## In-depth explanation

Correct Answer
Use a visible, individualized plan that addresses orthostasis, toileting, mobility, vision, cognition, and the client's goals.

Why It Fits
The client has several modifiable fall risks that require different targeted interventions rather than one universal restriction.

Clinical Picture
Patient-centered fall prevention links formal risk assessment to a tailored plan and consistent execution by the client, family, and care team.

Memory Link
Match the prevention step to the reason this client might fall.

NCLEX Rule
Assess, individualize, communicate, carry out, and revise the fall plan when risks or function change.

Why the Alternatives Fail
Restraint-like side-rail use, sedating the client, or telling the client never to move can increase harm and does not correct the underlying risks.

Sources
1AHRQ Fall TIPS Patient-Centered Fall Prevention Toolkit
2NCSBN 2026 NCLEX-RN Test Plan

## Clinical scenario

Medical unit
An older adult admitted with pneumonia has orthostatic dizziness, urinary urgency, new weakness, and intermittent confusion at night. The client wears bifocals, uses a cane at home, and wants to remain as independent as possible. The nurse and client are developing a bedside fall-prevention plan.

## Key concepts

- **Orthostatic hypotension** — A clinically important blood-pressure drop after standing that may cause dizziness or fainting.
- **Fall-risk assessment** — A structured evaluation of intrinsic, medication, environmental, and functional factors that may cause a fall.
- **Tailored intervention** — A prevention action selected to address a specific risk identified for an individual client.

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