It has been determined that all of the following clients are at risk f

It has been determined that all of the following clients are at risk for falling. Which one requires the nurse’s priority for ambulation?

1. A 16-year-old with a sprained ankle being discharged from the emergency de-partment
2. A 54-year-old who has taken the initial dose of an antihypertensive medication
3. A 45-year-old postoperative client up for the first time since knee surgery
4. An 81-year-old who is asthmatic and had a hip replaced 18 months ago

ANSWER

ANS: 3
Disease, injury, pain, physical development (e.g., age), and life changes (e.g., pregnancy) com-promise the ability to remain balanced. Medications that cause dizziness and prolonged immobil-ity also affect balance. Although all the options represent a potential risk for falling, the postop-erative client has both prolonged immobility and physical injury (surgery) and so is at greatest risk.