Why Falls Matter
Falls are the leading cause of injury and injury-related death in adults 65 and older — and the most important point for the exam is that most falls are preventable.
- Hip fractures from falls are a leading reason older adults are placed in long-term care, with high rates of complications and death in the year that follows.
- Head injuries are especially dangerous in patients on anticoagulants (warfarin, apixaban) — even a minor bump can bleed.
- Fear of falling starts a downward spiral: the person moves less → muscles weaken (deconditioning) → balance worsens → fall risk goes up.
Because most falls are preventable, fall prevention is one of the most heavily tested safety topics on the NCLEX-PN. Expect questions on who is at risk, how to keep them safe, and what to do after a fall.
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Risk Factors
Fall risk splits into intrinsic factors (inside the patient) and extrinsic factors (the environment and medications). The more factors stacked together, the higher the risk.
Intrinsic (the patient)
A previous fall — the strongest single predictor
Gait, balance, and muscle weakness
Orthostatic hypotension & dizziness
Poor vision; cognitive impairment or delirium
Urinary urgency/incontinence (rushing to the toilet)
Foot problems; chronic disease (stroke, Parkinson's, arthritis)
Extrinsic (environment & meds)
Medications — sedatives, antihypertensives, and more
Throw rugs, clutter, cords, wet floors
Poor lighting; no night-light
No grab bars or raised toilet seat
Improper footwear (socks, loose slippers)
Misused or out-of-reach assistive devices
A prior fall is the number-one predictor of the next one. One screening question identifies many of your highest-risk patients — make it routine.
Medications That Cause Falls
Fall-risk-increasing drugs work mostly by causing sedation, confusion, or low blood pressure. Reviewing them is a core part of prevention.
- Sedative-hypnotics & benzodiazepines+ "Z-drugs"
- Sedation, slowed reaction, confusion. Among the biggest fall risks (and on the Beers list).
- Antipsychotics & antidepressants
- Sedation, dizziness, and orthostatic drops in blood pressure.
- Opioids
- Sedation, dizziness, and impaired thinking.
- Antihypertensives & diuretics
- Orthostatic hypotension; diuretics also drive urgent trips to the toilet.
- Anticholinergics
- Blurred vision and confusion (see the polypharmacy guide on anticholinergic burden).
- Blood-sugar-lowering drugs
- Hypoglycemia causes weakness, shakiness, and confusion.
It isn't just one drug — polypharmacy itself raises fall risk. Each added sedating or blood-pressure-lowering drug compounds the danger, so a medication review belongs in every fall-prevention plan. See Polypharmacy & Medication Safety.
Fall-Risk Assessment
Assess fall risk on admission and after any change in condition, medication, or environment — not just once.
The Morse Fall Scale — 6 factors
A widely used screening tool. A higher total score means higher risk (the cutoff for "high risk" varies by facility):
- History of falling (recent fall)
- Secondary diagnosis (more than one medical condition)
- Ambulatory aid (cane, walker, or holding furniture)
- IV therapy / saline lock
- Gait/transferring (weak or impaired)
- Mental status (overestimates ability / forgets limitations)
Other tools you may see: the Timed Up and Go and the Hendrich II Fall Risk Model.
? How do you check for orthostatic hypotension, and what makes it positive?
Prevention That Works
Most prevention is simple and environmental. Know the universal precautions that apply to every at-risk older adult.
- Bed & call light
- Bed in the lowest position, locked wheels; call light and personal items within reach; answer calls promptly.
- Footwear & floor
- Non-skid footwear; clear, dry, clutter-free path; clean up spills immediately.
- Lighting & vision
- Good lighting and a night-light; glasses and hearing aids on and within reach.
- Toileting
- Proactive, scheduled toileting — urgency and rushing to the bathroom cause many falls.
- Mobility & strength
- Assistive devices within reach and used correctly; physical therapy, strength and balance training; review for vitamin D as ordered.
- Monitoring
- Hourly rounding, fall-risk identification (armband/signage), rooms near the nurses' station; bed/chair alarms as an adjunct (not a substitute for supervision).
- Medications
- Review and minimize fall-risk drugs with the prescriber.
The highest-yield answers are the simple, universal ones: bed low and locked, call light reachable, non-skid footwear, clear path, prompt toileting. Pick the basic safety intervention over restraints or alarms.
Restraints Aren't the Answer
Restraints do not prevent falls — and can make injuries worse. Always use the least restrictive approach first.
- Restraints cause harm — deconditioning, agitation, pressure injuries, and even strangulation or death.
- Try alternatives first — bed/chair alarms, frequent rounding, scheduled toileting, lower beds, keeping the patient nearby, family presence, and activities/distraction.
- If a restraint is truly necessary — it requires a provider order with specific criteria, the least restrictive type, regular monitoring and release, and ongoing reassessment. It is a last resort, never routine fall prevention.
On the exam, restraints are almost never the right fall-prevention answer. Choose the least-restrictive option. A restrained, confused older adult may struggle and be injured more severely than an unrestrained one.
After a Fall
If you find a patient on the floor, do not rush to lift them. Assess for injury first — moving an injured patient can do more harm.
? A nurse finds an older adult on the floor reporting hip pain, with the right leg shortened and turned outward. What does this suggest, and what's the priority?
Frequently Asked Questions
Common student questions on this topic.
What is the strongest predictor that an older adult will fall?
How do you measure orthostatic (postural) blood pressure?
Should restraints be used to prevent falls?
What should the nurse do first when finding a patient who has fallen?
Which medications most increase fall risk in older adults?
Why is a hip fracture so serious for an older adult?
Quick-Reference Cheatsheet
Every key point from this guide on a single printable page.
Falls: Risk & Prevention Cheatsheet
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