The nurse plans a safety program for clients on a medical-surgical unit and reviews the admission diagnoses of clients over the past year. Which client diagnosis represents the greatest likelihood of falling on the unit?
1. Pacemaker battery replacement
2. Heart failure with pulmonary edema
3. Arthroscopy after a college football injury
4. Right salpingectomy for ectopic pregnancy
2
2. The client with heart failure and pulmonary edema is most likely to fall because this client is likely to be older, have decreased exercise tolerance, and taking diuretics to reduce total body fluid. Clients with heart failure take other medications, including antihypertensive agents that increase the risk of falls due to confusion, dizziness, orthostatic hypotension, or getting to the bathroom.
1. This client is likely to be older but has a history of a permanent pacemaker; battery replacement is usually a low-risk, routine procedure.
3. This client is most likely to be a muscular, young adult who is stable while ambulating.
4. This client is of childbearing age and likely to be ambulatory.
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