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A client with right-sided weakness becomes dizzy, loses balance, and begins to fall while the nurse is assisting with ambulation. Which nursing actions would best prevent injury to the client and nurse while guiding the client to a horizontal position on the floor?

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Final answer:

To prevent injury when a client experiences a loss of balance and begins to fall, the nurse should stay close to provide support, use a wide stance for stability, bend the knees, guide the client to the floor carefully, and assess for injuries once the client is down.

Step-by-step explanation:

When a client with right-sided weakness starts to feel dizzy and loses balance during ambulation, it is vital to prevent injury to both the client and the nurse. The nurse should guide the client to a horizontal position on the floor using these steps:

  • Stay close to the client to provide support.
  • Position one foot between the client's feet for stability and spread the other foot out sideways to create a wide base of support.
  • Bend your knees to lower your center of gravity, which will increase your stability.
  • Use your body to break the client's fall, allowing them to slide against your leg and gently down to the floor.
  • If possible, protect the client's head from hitting the floor.
  • Once on the floor, stay with the client, provide reassurance, assess for any injuries, and call for additional help if necessary.

It's important to maintain proper body mechanics throughout this process to avoid injury to yourself and to ensure the safest descent for the client. Consider utilizing assistive devices like a cane or a walker in future ambulation practice to enhance stability and reduce the risk of falls.

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