Which action should the nurse take to reduce fall risk for a client who had a stroke?

Which action should the nurse take to reduce fall risk for a client who had a stroke?

• A. Assign the client to a private room
• B. Keep 4 side rails up while the client is in bed
• C. Monitor the client at least once every hour
• D. Request a PRN prescription for restraints

Answer: (C)

Constant, attentive monitoring is essential for reducing fall risk in a client who had a stroke. Stroke survivors often have unilateral weakness, impaired balance, altered sensation, and cognitive changes that make them more prone to wandering or attempting unsafe transfers. Checking the patient at least once every hour allows the nurse to provide timely assistance with getting in and out of bed, standing, and moving around, as well as to assess tolerance to activity, adjust the safety plan, and respond quickly if dizziness, fatigue, or weakness increases. This proactive supervision helps prevent falls while supporting independence. Assigning a private room by itself doesn’t directly address fall risk, since safety depends more on supervision, environmental safety, and timely assistance. Keeping four side rails up is typically a restraint and can increase injury risk if the patient tries to climb out or becomes agitated, and it does not address the underlying causes of falls. Requesting a PRN prescription for restraints is not appropriate and can lead to harm and rights concerns. Prioritizing hourly monitoring provides real, active safety for the patient.

Constant, attentive monitoring is essential for reducing fall risk in a client who had a stroke. Stroke survivors often have unilateral weakness, impaired balance, altered sensation, and cognitive changes that make them more prone to wandering or attempting unsafe transfers. Checking the patient at least once every hour allows the nurse to provide timely assistance with getting in and out of bed, standing, and moving around, as well as to assess tolerance to activity, adjust the safety plan, and respond quickly if dizziness, fatigue, or weakness increases. This proactive supervision helps prevent falls while supporting independence.

Assigning a private room by itself doesn’t directly address fall risk, since safety depends more on supervision, environmental safety, and timely assistance. Keeping four side rails up is typically a restraint and can increase injury risk if the patient tries to climb out or becomes agitated, and it does not address the underlying causes of falls. Requesting a PRN prescription for restraints is not appropriate and can lead to harm and rights concerns. Prioritizing hourly monitoring provides real, active safety for the patient.