After assessing the older man in his bed, the nurse determines that he is at high risk for falls. The nurse leaves the room to get a fall risk sign and returns to find him on the floor pleading for help

Question

Which of the following was the most important intervention the nurse should have implemented to prevent this event? a. Call for someone to bring the sign.
b. Show the older man how to use the call bell.
c. Provide a urinal and drinking water.
d. Instruct the patient to call for help.

Answer 1

D
The nurse accomplished the most important aspect of fall prevention with the assessment. How-ever, in an attempt to communicate the fall risk to other staff members, the nurse failed to com-municate properly to the patient about fall prevention before leaving the room. Calling for someone to bring the sign would have been a reasonable approach to communicating the risk of falls, but it does not take the place of directly instructing the patient about prevention. The needs of an older adult can contribute to the risk of falls as an individual leans and reaches for some-thing; therefore call bell instructions are a reasonable approach for preventing falls. However, before providing the call bell instructions, the nurse needed to tell him to call for help. A urinal and drinking water are common items that an older man needs, but reaching for them can con-tribute to falls.