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.