Fall-risk scoring gives 3 points to benzodiazepines, 2 to antidepressants and 1 to diuretics, and a total of 6 or more means elevated risk. A client takes one of each. What should the nurse do?

1. 1Take no action because the combined score of the client is low
2. 2Ask the pharmacist or prescribing provider to evaluate the medications for possible change
3. 3Hold all three medications until the next shift and then give them as ordered
4. 4Apply a restraint to the client in order to prevent a fall from the bed or chair

Source: Nursing Fundamentals, 2nd edition (Open RN, Chippewa Valley Technical College, 2024), Safety: Interventions Based on Risk Factors. Licensed under CC BY 4.0.