A patient has fallen in his room. The nurse who admitted the patient says, "But when I assessed his fall status, he was only moderate risk.". How should the nurse manager interpret this situation?
1. The fall assessment was not completed correctly.
2. Fall assessment alone is not sufficient to protect patients.
3. Something must have changed in the patient's condition since the assessment was completed.
4. The patient must be confused.
2
Rationale 1: The nurse reports the patient was at moderate risk for fall, so there is no reason to think the assessment was incorrect.
Rationale 2: Fall assessment alone does not prevent falls. The nurse must interpret the information and intervene to keep the patient as safe as possible.
Rationale 3: The nurse reports that the patient was at moderate risk for fall. There may have been changes in the patient's condition, but because moderate risk already existed, there is no reason to believe this must have occurred.
Rationale 4: There is nothing to indicate that the patient is confused. Patients who are cognitively clear may fall if they have muscle weakness or other conditions.
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