Level: Clinical
Difficulty: Medium
Subtopic: Falls prevention
NCLEX: An older adult with a history of falls tries to get out of bed unassisted and is unsteady. What should the nurse…
Nursing fundamentals Basic Care and Comfort Safety and Infection Prevention and Control
Case Study
An older adult with a history of falls tries to get out of bed unassisted and is unsteady. What should the nurse do first?
Question
A. Stay with the client, call for assistance, and reassess fall risk and safety devices.
B. Remind the client to use the call light after returning to the nurses' station.
C. Apply restraints to prevent another fall attempt.
D. Complete morning medications before addressing mobility.
B. Remind the client to use the call light after returning to the nurses' station.
C. Apply restraints to prevent another fall attempt.
D. Complete morning medications before addressing mobility.
Rationale
Correct answer: A. Stay with the client, call for assistance, and reassess fall risk and safety devices.
Rationale: Immediate safety and supervision take priority; restraints are a last resort after other fall-prevention measures.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Immediate safety and supervision take priority; restraints are a last resort after other fall-prevention measures.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.