# Situation: A 78-year-old woman is admitted to the adult medical ward with community-acquired pneumonia. She fell at home 2 months ago. She also has type 2 diabetes, has a peripheral intravenous (IV) line, walks by holding on to the furniture, has a weak gait, and is oriented to her own ability. The ward uses the Morse Fall Scale and treats a score of 45 or more as high risk. What is her Morse Fall Scale score on admission?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=629760  
> language: ko  
> subject: Nursing Practice III — Care of Clients with Problems in Surgery, Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations

## 문제

Situation: A 78-year-old woman is admitted to the adult medical ward with community-acquired pneumonia. She fell at home 2 months ago. She also has type 2 diabetes, has a peripheral intravenous (IV) line, walks by holding on to the furniture, has a weak gait, and is oriented to her own ability. The ward uses the Morse Fall Scale and treats a score of 45 or more as high risk.

What is her Morse Fall Scale score on admission?

## 보기

1. 100 points **✔ 정답**
2. 110 points
3. 75 points
4. 85 points

**정답: 1**

## 해설

Morse Fall Scale points: history of falling within 3 months 25, secondary diagnosis 15, holding on to furniture 30, IV line or saline lock 20, weak gait 10, and oriented to own ability 0. The total is 25 + 15 + 30 + 20 + 10 + 0 = 100, well above the ward's high-risk cutoff of 45.

## 심화 해설

Scoring the Morse Fall Scale

The Morse Fall Scale (MFS) assigns points across six items. For this patient, each item is scored as follows.

| MFS item | Patient finding | Points |
| --- | --- | --- |
| History of falling within 3 months | Fell at home 2 months ago | 25 |
| Secondary diagnosis | Type 2 diabetes plus pneumonia | 15 |
| Ambulatory aid | Walks by holding on to furniture | 30 |
| IV line or saline lock | Peripheral IV line present | 20 |
| Gait | Weak gait | 10 |
| Mental status | Oriented to own ability | 0 |

Adding the item scores gives 25 + 15 + 30 + 20 + 10 + 0 = 100. This is well above the ward's high-risk cutoff of 45, so the patient is classified as high risk for falls on admission.

The single highest-scoring item here is ambulatory aid at 30 points, because holding on to furniture indicates the patient relies on unstable environmental support rather than a proper assistive device. The history of falling within the past 3 months adds another 25 points, which is clinically meaningful because a recent fall is one of the strongest predictors of a subsequent fall during hospitalization. The secondary diagnosis item is met because the patient has more than one active medical diagnosis: community-acquired pneumonia and type 2 diabetes. The IV line contributes 20 points, reflecting both the physical tether of tubing and the tendency for patients with IV access to attempt unassisted mobility while managing the line. A weak gait adds 10 points, and the patient's orientation to her own ability contributes 0 points because she can accurately assess her own mobility limitations.

Watch out! The mental status item is scored 0 when the patient is oriented to their own ability, even if the patient is older or has multiple comorbidities. This item only adds points when the patient overestimates their ability or forgets their limitations.

Key point! The MFS is a screening tool, not a diagnostic test. A score of 100 indicates high risk, but the scale alone does not identify which specific fall prevention interventions are needed. The retrospective VHA study notes that the MFS remains widely used to determine fall risk across healthcare institutions despite known limitations, which means nurses must combine the score with clinical judgment and individualized mobility assessment.

The correct total is 100 points, matching option 1.

## 임상 시나리오

Morse Fall Scale Bedside ScoringSix-item total drives fall prevention level
Score each item at admission: fall within 3 months 25, secondary diagnosis 15, holding onto furniture 30, IV line or saline lock 20, weak gait 10, oriented to own ability 0. Total 100 exceeds the ward cutoff of 45, so classify as high risk.

The largest contributor is ambulatory aid at 30 because furniture support is unstable. A recent fall adds 25 and is one of the strongest predictors of another fall during hospitalization.

CautionDo not omit the secondary diagnosis item when pneumonia and diabetes coexist. Also reassess after any fall, sedation change, or transfer to a new unit.

## 핵심 개념

- **Morse Fall Scale** — Six-item tool scoring fall risk; 45 or more indicates high risk in many settings.
- **History of falling** — Fall within 3 months adds 25 points and strongly predicts future inpatient falls.
- **Ambulatory aid** — Holding onto furniture scores 30 points, reflecting unstable environmental support.
- **Secondary diagnosis** — Two or more active diagnoses add 15 points.
- **High-risk cutoff** — Threshold score, often 45, that triggers fall prevention interventions.

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