A nurse is caring for four clients. Which of the following clients is at the greatest risk for falling?
A.
A client who has diminished vision ambulating in well-lit areas
B.
A client who received a diuretic 30 min ago
C.
A client who requires assistance with ambulation
D.
A client who had a tonic-clonic seizure 2 hr ago
The Correct Answer and Explanation is:
The client at the greatest risk for falling is:
D. A client who had a tonic-clonic seizure 2 hours ago
Explanation
Falling is a significant concern in nursing care, particularly for clients who are at an increased risk due to various medical conditions and recent events. The risk of falls can be influenced by a number of factors, including medication effects, physical assistance needs, and recent medical events.
A. A client who has diminished vision ambulating in well-lit areas
Although diminished vision can increase the risk of falling, well-lit areas can help mitigate this risk. Adequate lighting improves visibility and helps clients with vision impairments navigate their environment more safely. However, this client may still be at risk if they have difficulty seeing or if other factors contribute to their instability.
B. A client who received a diuretic 30 minutes ago
Diuretics increase urine output, which can lead to frequent trips to the bathroom. This might increase the risk of falls, particularly if the client is experiencing orthostatic hypotension (a drop in blood pressure upon standing). However, the immediate risk is less compared to the residual effects of recent seizures.
C. A client who requires assistance with ambulation
Clients who need assistance with ambulation are at risk for falls due to their reliance on others for support. While this client does have a higher risk of falling compared to those who can walk independently, their risk is less compared to someone who has experienced a recent seizure.
D. A client who had a tonic-clonic seizure 2 hours ago
A tonic-clonic seizure involves a loss of consciousness and muscle control, which significantly impacts balance and coordination. Even 2 hours post-seizure, the client may still experience residual effects such as fatigue, disorientation, and impaired motor function, all of which contribute to an increased fall risk. Seizure recovery can also be associated with muscle soreness and weakness, which can further compromise stability. Therefore, this client is at the greatest risk for falling due to the immediate aftermath of the seizure and its lingering effects.
In summary, a client who had a tonic-clonic seizure 2 hours ago is at the greatest risk for falling due to the potential ongoing effects of the seizure on their physical and cognitive function.