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Difficulty: EasyAccident, Error, and Injury Prevention

An admission assessment reveals that a newly arrived client has right-sided hemiparesis due to a recent stroke. The client is documented as a high fall risk. Which nursing action is most appropriate to ensure a safe environment and prevent injury?

  1. Place the call light, water pitcher, and personal belongings on the client's left side.Answer
  2. B
    Raise all four side rails on the bed to keep the client from getting up unassisted.
  3. C
    Instruct the unlicensed assistive personnel (UAP) to complete the admission fall risk assessment.
  4. D
    Initiate contact precautions immediately to minimize the risk of environmental cross-contamination.

Answer

Place the call light, water pitcher, and personal belongings on the client's left side.
Placing frequently used items on the client's unaffected (left) side ensures they can easily reach for what they need without overextending, losing their balance, or attempting to get out of bed unsafely, thereby directly reducing the risk of a fall.

Step-by-Step Solution

1
Evaluate the client's specific physical deficits and safety risks.
The client has right-sided hemiparesis (weakness) and is at a high risk for falling.
Identifying specific physical limitations is required to implement targeted, individualized safety measures.
2
Determine the safest environmental setup based on the deficit.
Frequently used items must be placed on the unaffected (left) side.
Ensuring items are easily reachable by the client's strong hand prevents overreaching, loss of balance, and subsequent falls.

Key Concept

Environmental modification for fall prevention in clients with unilateral weakness.
Estimated Time:45s
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Topics

Accident, Error, and Injury Prevention

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