Question

While the nurse is assessing an older pt fall risk, the pt reports living at home alone and never falling. Which action should the nurse take?

Answer 1

The nurse should perform a comprehensive fall risk assessment on the patient using evidence-based tools, regardless of the patient's claim of never having fallen. It is important to evaluate potential risk factors and educate the patient on fall prevention strategies to reduce the risk of future falls.

Step-by-step explanation:

When assessing an older patient who lives alone and reports never falling for fall risk, the nurse should still perform a comprehensive risk assessment. Despite the absence of previous falls, it is important to evaluate the patient's environment, mobility, medications, vision, and overall health status. These factors can contribute to fall risk. The nurse should consider evidence-based assessment tools like the Morse Fall Scale or the STRATIFY tool to evaluate the risk and implement appropriate preventive measures.Moreover, educating the patient on fall prevention strategies, such as removing trip hazards, installing grab bars, ensuring proper lighting, and possibly using a personal emergency response system, is crucial. Addressing potential risk factors proactively helps to reduce the likelihood of future falls, which is important since falls can result in serious injury for older adults and can lead to further complications.