20.5: Chapter 5 (Safety)
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.