Chapter 5 (Safety)

Open Resources for Nursing (Open RN)

Answer Key to Chapter 5 Learning Activities

1. Risk factors: hip fracture, morphine pain medication, diminished eyesight and hearing, ambulates with walker, weakness, experience of recent fall.

2. Morse Fall Risk Assessment Scoring:

  • History of fall – 25
  • Walker – 15
  • Weak Gait -10
  • Total: 50 – High Risk

3. Interventions to address risk factors:

  • Provide adequate lighting and night-light
  • Use of half rails
  • Encourage rest
  • Place articles within reach at bedside
  • Use elevated toilet seat in bathroom
  • Use assistive devices, glasses and hearing aids
  • Obtain orthostatic blood pressures
  • Wear shoes or slippers with non-skid soles

4. Potential response: “Mr. Moore, your safety is most important and we need to ensure you do not fall. If you have a bowel movement, we will clean it up. Moving forward, it may be helpful for us to have a commode chair closer to your bedside so we do not need to travel so far if urgency arises.”

Answers to interactive elements are given within the interactive element.


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