Which finding indicates a client at the highest risk for falls in an extended care facility?

A Mini-Mental State Exam (MMSE) score of 22 indicates a level of cognitive impairment that can significantly increase the risk of falls. The MMSE is a widely used tool to assess cognitive function, and scores below 24 suggest difficulties with orientation, attention, and memory. In a healthcare setting, cognitive impairment can lead to poor judgement, difficulties in following instructions, and an inability to recognize potential hazards in the environment, all of which can contribute to an increased likelihood of falls.

While verbal complaints of dizziness, recent surgery, and the use of a mobility aid are certainly factors that can influence fall risk, they do not indicate cognitive impairment itself. A client who is confused or does not understand their surroundings—or who may not be able to make safe decisions about their movements—presents a more significant challenge in preventing falls compared to the other listed factors. The cognitive aspects derived from a lower MMSE score create a higher risk profile, making this finding particularly relevant in identifying clients vulnerable to falls in an extended care setting.