Deck 11: Falls

Question 1

An older adult patient in a long-term care facility is at risk for injury because of confusion.The patient's gait is stable.What is the best method of restraint to prevent injury to the patient?

A) Geriatric chair
B) Ambularm bracelet
C) Vest restraint
D) Wrist or ankle restraint or both

Answer 1

Ambularm bracelet

Question 2

What should be the first intervention when a nurse finds that a patient has fallen?

A) Ask the patient to stand up.
B) Document the fall according to agency policy.
C) Remove or correct the cause of the fall.
D) Assess the circumstances of the fall and any injuries sustained.

Answer 2

Assess the circumstances of the fall and any injuries sustained.

Question 3

Which unexpected circumstance best defines a fall?

A) Falls to the ground, floor, or lower level
B) Loses consciousness, resulting in injury
C) Loses balance, resulting from a lack of equilibrium
D) Injures self, resulting from a side effect of a medication

Answer 3

Falls to the ground, floor, or lower level

Question 4

Where should a patient with a visual impairment of the left eye place items that are frequently used to prevent the risk of injury?

A) On the patient's left side
B) In the patient's bathroom
C) In the patient's closet
D) On the patient's right side

Question 5

An older adult patient with osteoporosis is at risk for falls.What should a nurse advise the patient to do in order to maintain safety in the home?

A) Take the rubber mat out of the shower.
B) Install a grab rail in the bath and shower and by the toilet.
C) Avoid rubber-soled shoes.
D) Avoid exercise.

Question 6

A nurse is assessing the potential risk factors a patient may have for falling.Which two major factors cause falls?

A) Mental and emotional factors
B) Aging and physical factors
C) Genetic and environmental factors
D) Intrinsic and extrinsic factors

Question 7

The Omnibus Reconciliation Act (OBRA)was enacted to protect patients from unnecessary restraint in long-term care facilities.According to OBRA regulations, what is a permissible reason to restrain a patient?

A) Staffing level is inadequate, and nurses are unable to check on the patient at regular intervals.
B) The patient is verbally abusive to the nursing staff.
C) The patient is at an extremely high risk for a fall that is life threatening.
D) Medical procedures cannot be performed because the patient is not being cooperative.

Question 8

A nurse assesses a resident in a long-term care facility with the "get up and go" technique.What should this involve observing the resident do?

A) Walk carefully through a cluttered area without incident.
B) Rise from the bed, and go to the bathroom.
C) Sit and rise from an armless chair.
D) Ambulate in a straight line for 1 foot.

Question 9

What recommendation should a nurse make to the family of a patient diagnosed with ataxia when preparing discharge to home?

A) Remove all scatter rugs from the home.
B) Rearrange the bedroom furniture.
C) Arrange for someone to stay with the patient 24 hours a day.
D) Purchase oversized shoes so that they are easy to get on.

Question 10

A nurse in a long-term care facility determines the need to place a vest restraint on a patient.The patient does not want the vest restraint applied.What nursing action should be implemented?

A) Apply the restraint anyway.
B) Call the physician and obtain an order for the restraint.
C) Medicate the patient with a sedative and then apply the restraint.
D) Compromise with the patient and use wrist restraints.

Question 11

A nurse is caring for an older adult patient who has undergone a total hip replacement.What is the best action to reduce the risk of further injury?

A) Leave all the lights on in the room at night.
B) Leave the side rails down at all times to enable the patient to get to the bathroom quickly.
C) Keep the call bell and other frequently used items in easy reach.
D) Keep the bed in the high position to discourage the patient from getting out of bed without assistance.

Question 12

A nurse explains that older adults account for a large percentage of the total deaths resulting from falls.What is this percentage?

A) 13%
B) 27%
C) 40%
D) 72%

Question 13

How often should a nurse remove and release restraints when caring for a patient who requires wrist restraints?

A) Once every 8 hours for at least 30 minutes
B) Once every 4 hours for at least 15 minutes
C) Once every 2 hours for at least 10 minutes
D) Once every 1 hour for at least 5 minutes

Question 14

Which patient population is at greatest risk for injury from falls?

A) Toddler
B) Teenager
C) Middle-aged adult
D) Older adult

Question 15

A patient has asked a nurse to assist him to ambulate to the bathroom.The nurse is aware that the patient is currently taking an antidepressant medication.What action should the nurse implement?

A) Never leave the patient alone in his room.
B) Ask the patient if he could use the bedside commode instead of going to the bathroom.
C) Make suicidal precautions part of the care plan.
D) Ask the patient to sit on the side of the bed for a minute or two before standing and then stand slowly.

Question 16

A nurse is talking to the family of a patient who has fallen several times.What is the most important intervention for preventing falls that the nurse to relay to this family?

A) Prevention
B) Hospitalization
C) Continuous observation
D) Restraint

Question 17

In reviewing a patient's medication administration record, a nurse is aware that some medications are considered to be chemical restraints.Which medication is considered a chemical restraint?

A) Warfarin (Coumadin)
B) Alprazolam (Xanax)
C) Isosorbide (Isordil)
D) Ibuprofen (Motrin)

Question 18

A nurse is admitting a new patient to the nursing unit.When conducting the admission procedure, what is important for the nurse to ask in order to assess the patient's risk for falling?

A) "How many times have you fallen before?"
B) "How many hours do you sleep at night?"
C) "What are your eating habits?"
D) "Do you smoke?"

Question 19

What is the most appropriate nursing intervention after a patient has fallen?

A) Apply a vest restraint.
B) Have the patient begin ambulating as soon as possible.
C) Administer haloperidol (Haldol)as prescribed or as needed.
D) Apply wrist restraints.

Question 20

What should discharge planning for a patient who lives alone and is at high risk for falling include?

A) Cannot go home unless someone is with him all the time.
B) Must go to a long-term care facility.
C) Can wear devices around the neck that can signal for help.
D) Needs to be aware of the dangers of living alone.

Question 21

A nurse is aware that many residents in a long-term care facility refuse to wear the hip protector garment.What reason do residents state makes them resistive to wear this protective garment?

A) It is uncomfortable.
B) It is too expensive.
C) It is degrading.
D) It is too easily soiled.

Question 22

In what ways might people who have a fear of falling alter their lifestyle? (Select all that apply.)

A) Restrict physical activities.
B) Restrict social activities.
C) Become more dependent.
D) Have increased need for residency in a long-term care facility.
E) Become depressed.

Question 23

A nurse helps the physical therapist teach residents in a long-term care facility how to diminish the risk of injury from a fall by teaching them rotation maneuvers to help them avoid falling _______.

Question 24

A nurse is aware that of all the reported falls in the United States, only 1% to 5% result in a ______.

Question 25

A home health nurse cautions the family of a frail 82-year-old woman about the intrinsic factors that may be a potential cause of injury.Which intrinsic factors should be included? (Select all that apply.)

A) Diminished vision
B) Pet cats
C) Cluttered bedroom
D) Wearing loose house slippers
E) Generalized weakness

Question 26

What should the home health nurse recommend to a patient if a fall occurs at home?

A) Assume a crawling position and push up from the floor.
B) Pull self up using sturdy furniture.
C) Roll to a doorway and pull up using the door knob.
D) Place the right foot flat on floor and push up on the right knee.

Question 27

A nurse is teaching a patient methods for getting up after a fall.The nurse instructs the patient to pull up to a sitting position on the floor, shuffle the buttocks to a nearby piece of furniture, and pull up on the knees in front of the furniture.What should the nurse instruct the patient to do next?

A) Stand up.
B) Place hands on the floor for leverage.
C) Pivot so that the furniture is behind the body.
D) Sit back down.

Question 28

A nurse is trying to keep a confused resident from removing a feeding tube by following the "rule of least restriction." What should replace the wrist restraint?

A) Mittens
B) Vest restraint
C) Administration of a mild sedative
D) Tightly tucked sheet

Question 29

A nurse visiting a patient in the patient's home assesses the environment for extrinsic risk factors for falling.Which factors should the nurse have the patient or family correct?

A) No door thresholds are present.
B) The kitchen floor is clean, shiny, and slick.
C) Lamps have 60-watt bulbs.
D) The telephone is placed on the bedside table.

Question 30

A nurse is discussing the risk of falling with the family of a 75-year-old patient.The family asks, "Why are you so worried about her falling? She falls all the time and doesn't get hurt much." To which fact should the nurse's response relate?

A) Falls are the most frequent cause of accidental injury and death among older adults.
B) Worrying is probably unnecessary because she hasn't been hurt in the past.
C) Falls usually occur in institutional settings.
D) Falls by older adults are not preventable.

Question 31

A nurse suggests that a resident who is at risk for falling come to the _______ class to improve balance.