The nurse is conducting an admission interview and assessment on a cog

The nurse is conducting an admission interview and assessment on a cognitively impaired, unco-operative client for the risk for injury. Which of the following options will most likely provide the information to confirm the diagnosis?

1. Base the degree of risk on observable data at the time of the client’s current hos-pital admission.
2. Closely monitor the client’s behavior and habits until risk for injury can be rea-sonably determined.
3. Make certain critically sound assumptions are based on the client’s developmental stage and current cognitive stasis.
4. Interview the client’s family, friends, and/or caregivers regarding prehospitaliza-tion risk factors.

ANSWER

ANS: 4
In many cases family members are important resources in assessing a client’s fall risk. Families often are able to report on the client’s level of confusion and ability to ambulate.