The nurse is admitting an older adult female who uses two canes for ambulation.The patient is attended by her daughter,who quietly reorients her mother several times during the assessment process.The daughter reports that her mother was a smoker for many years,but has not smoked for the last 5 years.The patient wears incontinence underwear and has problems with constipation.The nurse would evaluate which of these findings as key risk factors from the Hendrich II Fall Risk Model? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.

Question

Quizplus · Accepted Answer

The Hendrich II Fall Risk Model identifies factors that increase a patient's risk of falling. In this scenario, the patient wearing incontinence underwear (C) indicates a higher risk due to the potential for urgent needs to use the bathroom, increasing the chance of falls. The need for frequent reorientation (D) suggests cognitive impairment, which is a recognized risk factor for falls. The use of a cane (E) indicates mobility issues, which also increases fall risk. Being female (A) and a history of tobacco use (B) are not identified as risk factors in the Hendrich II Fall Risk Model.

The Nurse Is Admitting an Older Adult Female Who Uses