Using the Morse Fall Risk scale (see exhibit), the nurse should initiate highest fall risk precautions for which of the following clients? 1. 84-year-old client with diabetes admitted with new-onset...

Using the Morse Fall Risk scale (see exhibit), the nurse should initiate highest fall risk precautions for which of the following clients?

1. 84-year-old client with diabetes admitted with new-onset confusion. The client reportedly fell at home last week, is currently on bed rest, and has normal saline infusing per saline lock.

2. 48-year-old alert and oriented client with quadriplegia admitted for wound care of a stage IV pressure ulcer, receiving IV antibiotics per a peripherally inserted central catheter.

3. 62-year-old client with a history of Parkinson's disease, admitted for pneumonia and receiving IV antibiotics. The client has fallen at home but is able to ambulate with a cane. During his hospitalization, he has gotten out of bed without calling for assistance.

4. 27-year-old client with acute pancreatitis receiving morphine sulfate IV every 2 hours as needed for pain; no significant medical history, smokes two packs of cigarettes per day; may be up independently; and has steady gait.