Questions: A nurse is preparing to conduct a fall risk screening on a client. Which of the following variables will the nurse use to evaluate the client? (Select all that apply.) Fall history Medical diagnosis Use of assistive devices Mental status Do-not-resuscitate status

A nurse is preparing to conduct a fall risk screening on a client. Which of the following variables will the nurse use to evaluate the client? (Select all that apply.)
Fall history
Medical diagnosis
Use of assistive devices
Mental status
Do-not-resuscitate status
Transcript text: A nurse is preparing to conduct a fall risk screening on a client. Which of the following variables will the nurse use to evaluate the client? (Select all that apply.) Fall history Medical diagnosis Use of assistive devices Mental status Do-not-resuscitate status
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Answer

The variables the nurse will use to evaluate the client for fall risk are:

  • Fall history
  • Medical diagnosis
  • Use of assistive devices
  • Mental status
Explanation
Fall history:

A history of previous falls is a significant predictor of future falls. If a client has fallen before, they are more likely to fall again, making this an essential variable in fall risk assessment.

Medical diagnosis:

Certain medical conditions, such as Parkinson's disease, stroke, or arthritis, can increase the risk of falls. Evaluating the client's medical diagnosis helps identify those at higher risk.

Use of assistive devices:

The use of assistive devices like canes, walkers, or wheelchairs can indicate mobility issues, which may increase fall risk. Assessing whether a client uses these devices is crucial in determining their fall risk.

Mental status:

Cognitive impairments, such as dementia or delirium, can affect a person's ability to recognize and avoid hazards, increasing the risk of falls. Evaluating mental status is an important part of the assessment.

Do-not-resuscitate status:

This status is related to end-of-life care preferences and does not directly impact fall risk. Therefore, it is not typically used in fall risk screening.

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