A patient has reduced muscle strength following a left-sided stroke and is at risk for falling. Which intervention is most appropriate for the nursing diagnostic statement Risk for falls?

Question

a. Keep all side rails down at all times.
b. Encourage patient to remain in bed most of the shift.
c. Place patient in room away from the nurses' station if possible.
d. Assist patient into and out of bed every 4 hours or as tolerated.

Answer 1

ANS: D
Risk for falls is a risk (potential) nursing diagnosis; therefore, the nurse needs to implement actions that will prevent a fall. Assisting the patient into and out of bed is the most appropriate intervention to prevent the patient from falling. Encouraging activity builds muscle strength, and helping the patient with transfers ensures patient safety. Encouraging the patient to stay in bed will not promote muscle strength. Decreased muscle strength is the risk factor placing the patient in jeopardy of falling. The side rails should be up, not down, according to agency policy. This will remind the patient to ask for help to get up and will keep the patient from rolling out of bed. The patient should be placed near the nurses' station, so a staff member can quickly get to the room and assist the patient if necessary.