A homecare nurse visits a client in the home to conduct a fall risk assessment. The nurse assesses the client and the home for extrinsic risk factors for falls. Which of the following are extrinsic risk factors? (Select all that apply.)
a. The client has an unsteady gait.
b. The client uses a cane, but the cane is not the appropriate size for the client.
c. The client's home is cluttered.
d. The client is on two different medications that cause orthostatic hypotension.
e. There are no grab bars in the client's bath-room.
ANS: B, C, E
Extrinsic risk factors are external to the patient and related to the physical environment and in-clude inadequate support devices. Options B, C, and E are extrinsic risk factors. Intrinsic risk factors are unique to each patient. Options A and D are intrinsic risk factors.
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