Difficulty: Medium
Average Score: 80%
Simulated
A nurse is developing a plan of care for an older adult who is at risk for falls. Which of the following actions should the nurse plan to include in the plan? (Select all that apply)
Correct answer
A;B;C;E
Rationale
The correct actions to include in the plan are A, B, C, and E.
A: Placing the bedside table within reach promotes independence and reduces the risk of falls when the client reaches for items without needing to get up.
B: Teaching balance and strengthening exercises enhances the client's physical strength and stability, reducing the risk of falls.
C: Providing information about home safety checks ensures the client's environment is free from hazards that could contribute to falls.
E: Locking beds and wheelchairs when not providing care prevents the client from moving independently, reducing the risk of falls.
D: Administering sedatives at bedtime increases the risk of falls due to potential side effects like dizziness and confusion. This does not address fall prevention.
In summary, choices A, B, C, and E promote fall prevention through environmental modifications, physical strength enhancement, and safety education, while choice D poses a risk of falls due to sedative use.
A: Placing the bedside table within reach promotes independence and reduces the risk of falls when the client reaches for items without needing to get up.
B: Teaching balance and strengthening exercises enhances the client's physical strength and stability, reducing the risk of falls.
C: Providing information about home safety checks ensures the client's environment is free from hazards that could contribute to falls.
E: Locking beds and wheelchairs when not providing care prevents the client from moving independently, reducing the risk of falls.
D: Administering sedatives at bedtime increases the risk of falls due to potential side effects like dizziness and confusion. This does not address fall prevention.
In summary, choices A, B, C, and E promote fall prevention through environmental modifications, physical strength enhancement, and safety education, while choice D poses a risk of falls due to sedative use.