When assessing an older adult for intrinsic risk factors for falls, the nurse is particularly interested in which of the following? (Select all that apply.)
a. An unsteady gait when asked to walk without assistance
b. The presence of throw rugs in the living room of the home
c. The patient's report that he wears correc-tive lenses
d. An inability to see changes in height be-cause of poor lighting
e. Evidence of short-term memory deficien-cy
A, C, E
The most salient observations for intrinsic risk factors for falls relate to gait, balance, stability, and cognition. Intrinsic risk factors are a combination of age-related changes and concurrent dis-ease. The other two options are extrinsic factors, which relate to the environment.
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