Difficulty: Medium
Average Score: 75%
Simulated
During the admission assessment, the nurse assesses the patient for fall risk. Which finding will alert the nurse to an increased risk for falls?
Correct answer
B
Rationale
The correct answer is B: The patient takes a hypnotic. Patients taking hypnotic medications are at an increased risk for falls due to the sedative effects of these drugs, causing dizziness, impaired balance, and confusion. This increases the likelihood of accidents and falls.
Incorrect Choices:
A: The patient is oriented. Being oriented does not necessarily indicate a decreased risk for falls.
C: The patient walks 2 miles a day. Regular exercise is beneficial for overall health but does not directly correlate with fall risk.
D: The patient recently became widowed. While emotional distress can affect a person's well-being, it does not directly indicate an increased risk for falls.
Incorrect Choices:
A: The patient is oriented. Being oriented does not necessarily indicate a decreased risk for falls.
C: The patient walks 2 miles a day. Regular exercise is beneficial for overall health but does not directly correlate with fall risk.
D: The patient recently became widowed. While emotional distress can affect a person's well-being, it does not directly indicate an increased risk for falls.