An ambulatory client is admitted to the extended care facility with a

An ambulatory client is admitted to the extended care facility with a diagnosis of Alzheimer’s disease. In using a falls assessment tool, the nurse knows that the greatest indicator of risk is:

1. Confusion
2. Impaired judgment
3. Sensory deficits
4. History of falls

ANSWER

ANS: 4
According to the falls assessment tool, the greatest indicator of risk is a history of falls. Accord-ing to the falls assessment tool, the second leading risk factor for falls is confusion. According to the falls assessment tool, impaired judgment is the fourth leading risk factor for falls. According to the falls assessment tool, sensory deficit is the fifth leading risk factor for falls.