Question 1

Following the "Rule of Least Restriction," the nurse who is trying to keep a confused resident from removing the feeding tube would replace the wrist restraint with:

Accepted Answer

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

Question 2

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

Accepted Answer

Tai Chi
The slow rhythmic movements of Tai Chi are helpful in improving balance.

Question 3

In assessing the potential risk factors a patient may have for falling,the nurse should keep in mind that the two major factors that cause falls are:

Accepted Answer

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

Question 4

The nurse is talking to the family of a patient who has fallen several times.She knows that her teaching should be aimed toward the most important intervention for falls,which is:

Accepted Answer

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

Question 5

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

Accepted Answer

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 
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 6

The nurse is teaching the 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,pull up on the knees in front of the furniture,and then:

Accepted Answer

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. 
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 7

When the nurse finds that a patient has fallen,the first intervention should be to:

Accepted Answer

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. 
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.

Question 8

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

Accepted Answer

Fracture
According t

Question 9

The older adult patient with osteoporosis is at risk for falls.To maintain safety in the home,the nurse would advise the patient to:

Accepted Answer

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. 
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 10

The 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.These are:

Accepted Answer

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

Question 11

When caring for a patient who requires wrist restraints,the nurse should remove and release the restraints once every:

Accepted Answer

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

Question 12

The Omnibus Reconciliation Act (OBRA)was enacted to protect patients from unnecessary restraint in long-term care facilities.According to OBRA regulations,one reason to restrain a patient would be if the:
A) Staffing level is inadequate, and nurses are unable to check on the patient at regular intervals.
B) Patient is verbally abusive to the nursing staff.
C) 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.

Accepted Answer

C
The only people who are considered res

Question 13

After a patient has fallen,the most appropriate nursing intervention is to:

Accepted Answer

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

Question 14

In reviewing a patient's medication administration record,the nurse is aware that some medications are considered to be chemical restraints.Of the following medications,the nurse recognizes the chemical restraint to be:

Accepted Answer

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

Question 15

The nurse assesses a resident in a long-term care facility with the "Get Up and Go" technique,which involves observing the resident:

Accepted Answer

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. 
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 16

Discharge planning for a patient who lives alone and is at high risk for falling should include telling the patient that he:

Accepted Answer

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. 
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 17

The nurse explains that the older adults account for a large percentage of the total deaths resulting from falls.This percentage is:

Accepted Answer

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

Question 18

The nurse points out that people who have a fear of falling may alter their lifestyle to the point that they:

Accepted Answer

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

Question 19

The nurse is admitting a new patient to the nursing unit.When conducting the admission procedure,assessing the patient's risk for falling is important by asking:

Accepted Answer

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?" 
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 20

The home health nurse recommends to a patient that if a fall occurs at home,the patient should:

Accepted Answer

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 right knee. 
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 right knee.

Exam 20: Falls

Following the "Rule of Least Restriction," the nurse who is trying to keep a confused resident from removing the feeding tube would replace the wrist restraint with:

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

In assessing the potential risk factors a patient may have for falling,the nurse should keep in mind that the two major factors that cause falls are:

The nurse is talking to the family of a patient who has fallen several times.She knows that her teaching should be aimed toward the most important intervention for falls,which is:

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

The nurse is teaching the 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,pull up on the knees in front of the furniture,and then:

When the nurse finds that a patient has fallen,the first intervention should be to:

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

The older adult patient with osteoporosis is at risk for falls.To maintain safety in the home,the nurse would advise the patient to:

The 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.These are:

When caring for a patient who requires wrist restraints,the nurse should remove and release the restraints once every:

After a patient has fallen,the most appropriate nursing intervention is to:

In reviewing a patient's medication administration record,the nurse is aware that some medications are considered to be chemical restraints.Of the following medications,the nurse recognizes the chemical restraint to be:

The nurse assesses a resident in a long-term care facility with the "Get Up and Go" technique,which involves observing the resident:

Discharge planning for a patient who lives alone and is at high risk for falling should include telling the patient that he:

The nurse explains that the older adults account for a large percentage of the total deaths resulting from falls.This percentage is:

The nurse points out that people who have a fear of falling may alter their lifestyle to the point that they:

The nurse is admitting a new patient to the nursing unit.When conducting the admission procedure,assessing the patient's risk for falling is important by asking:

The home health nurse recommends to a patient that if a fall occurs at home,the patient should:

The Health Care System

Patient Care Settings

Legal and Ethical Considerations

The Leadership Role of the Licensed Practical Nurse

The Nurse-Patient Relationship

Cultural Aspects of Nursing Care

The Nurse and the Family

Health and Illness

Nutrition

Developmental Processes

The Older Patient

The Nursing Process and Critical Thinking

Inflammation, infection, and Immunity

Fluids and Electrolytes

Pain Management

First Aid, emergency Care, and Disaster Management

Surgical Care

Intravenous Therapy

Shock

Immobility

Confusion

Incontinence

Loss, death, and End-Of-Life Care

The Patient With Cancer

The Patient With an Ostomy

Neurologic Disorders

Cerebrovascular Accident

Spinal Cord Injury

Acute Respiratory Disorders

Chronic Respiratory Disorders

Hematologic Disorders

Immunologic Disorders

Human Immunodeficiency Virus and Acquired Immunodeficiency Syndrome

Cardiac Disorders

Vascular Disorders

Hypertension

Digestive Tract Disorders

Disorders of the Liver, gallbladder, and Pancreas

Urologic Disorders

Connective Tissue Disorders

Fractures

Amputations

Pituitary and Adrenal Disorders

Thyroid and Parathyroid Disorders

Diabetes Mellitus and Hypoglycemia

Female Reproductive Disorders

Male Reproductive Disorders

Sexually Transmitted Infections

Skin Disorders

Eye and Vision Disorders

Ear and Hearing Disorders

Nose, sinus, and Throat Disorders

Psychologic Responses to Illness

Psychiatric Disorders

Substance-Related Disorders

Filters

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