Question

During a falls risk assessment, what action would the nurse take after learning the client experienced a recent fall?

A) Document the fall in the client's medical record
B) Advise the client to be more careful in the future
C) Conduct a thorough assessment of the circumstances surrounding the fall
D) Administer pain medication to alleviate any discomfort from the fall

Answer 1

When learning of a recent fall during a falls risk assessment, the priority action for a nurse is to conduct a thorough assessment of the factors that led to the fall, to develop a plan to prevent future incidents. Therefore, the correct option is c.

Step-by-step explanation:

During a falls risk assessment, when a nurse learns that the client experienced a recent fall, the appropriate action would be to conduct a thorough assessment of the circumstances surrounding the fall. This assessment should aim to identify the factors that contributed to the fall such as environmental hazards, medical conditions, or medication side effects. Through this process, the nurse can develop an individualized care plan to prevent future falls, which may include interventions like modifications to the living environment, rehabilitation exercises, or changes in medication. Documenting the fall in the client's medical record is also important, but the immediate priority is to understand the cause to prevent recurrence, so documenting alone is not sufficient.