Exam Guide

Fall Risk Factors the Nurse Should Identify

Safety & Infection Control · Question from the ATI PN Fundamentals 2023 Proctored Exam study set

Question: A nurse is assessing a client for fall risk. Which findings place the client at risk for a fall? (Select 4)

Correct answers:

  • Vision (macular degeneration)
  • Fear of falling
  • Balance (reports dizziness)
  • Environmental hazards (throw rugs)

Why this is the answer

Visual impairment, fear of falling (which alters gait and confidence), impaired balance, and environmental hazards such as throw rugs are all well-established, evidence-based fall risk factors.

The bigger concept

Fall risk is multifactorial and this 'Select 4' item mixes intrinsic factors (macular degeneration, dizziness, fear of falling) with an extrinsic one (throw rugs). Fear of falling is the factor students miss most — it changes gait, shortens stride, and reduces activity, which weakens the client further. Fall precautions the PN/VN can implement independently include a low bed, non-skid footwear, call light within reach, clutter-free path, and hourly rounding.

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