Question 1

In preparation for discharge home,the nurse caring for a patient with ataxia would recommend that the family:

Accepted Answer

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. 
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 2

The nurse clarifies that the best definition of a fall is a circumstance in which the patient unexpectedly:

Accepted Answer

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 
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

Question 3

The 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 ____________________.

Accepted Answer

Sideways
Rotation ma

Question 4

The patient has asked the nurse to assist him to ambulate to the bathroom.The nurse is aware that the patient is currently taking an antidepressant medication,so she should:

Accepted Answer

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 as 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. 
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 as 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 5

The nurse visiting a patient in the patient's home assesses the environment for extrinsic risk factors for falling.The nurse should have the patient or family correct which one of the following?

Accepted Answer

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. 
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 6

A patient with Parkinson disease would be at risk for falling as a result of:

Accepted Answer

A)  Quick movements 
B)  Unsteady, shuffling gait 
C)  Hemiparesis 
D)  Frequent loss of consciousness 
A)  Quick movements 
B)  Unsteady, shuffling gait 
C)  Hemiparesis 
D)  Frequent loss of consciousness

Question 7

The older adult patient in a long-term care facility is at risk for injury because of confusion.The patient's gait is stable.To prevent injury to the patient,the best method of restraint if prescribed would be a(n):

Accepted Answer

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

Question 8

Family members who brought a patient to the emergency department after she had fallen in her home are expressing their feelings of guilt.The nurse's most therapeutic response to the family would be:

Accepted Answer

A)  "Someone should really be staying with her to prevent her from falling." 
B)  "Let me see how long it will be before you can see the patient." 
C)  "Don't worry. You have nothing to feel guilty about." 
D)  "I can see you are worried." 
A)  "Someone should really be staying with her to prevent her from falling." 
B)  "Let me see how long it will be before you can see the patient." 
C)  "Don't worry. You have nothing to feel guilty about." 
D)  "I can see you are worried."

Question 9

The 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.The nurse should:

Accepted Answer

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. 
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 10

The 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." The nurse's response will be related to the fact that:

Accepted Answer

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. 
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 11

The nurse is caring for an older adult patient who has undergone a total hip replacement.To reduce the risk of further injury,the nurse would:

Accepted Answer

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. 
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

The nurse is aware that many residents in a long-term care facility refuse to wear the hip protector garment and use,as their excuse,that the garment is:

Accepted Answer

A)  Uncomfortable 
B)  Too expensive 
C)  Degrading 
D)  Too easily soiled 
A)  Uncomfortable 
B)  Too expensive 
C)  Degrading 
D)  Too easily soiled

Question 13

The nurse is aware that the patient at greatest risk for injury from falls is the:

Accepted Answer

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

Exam 20: Falls

In preparation for discharge home,the nurse caring for a patient with ataxia would recommend that the family:

The nurse clarifies that the best definition of a fall is a circumstance in which the patient unexpectedly:

The 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 ____________________.

The patient has asked the nurse to assist him to ambulate to the bathroom.The nurse is aware that the patient is currently taking an antidepressant medication,so she should:

The nurse visiting a patient in the patient's home assesses the environment for extrinsic risk factors for falling.The nurse should have the patient or family correct which one of the following?

A patient with Parkinson disease would be at risk for falling as a result of:

The older adult patient in a long-term care facility is at risk for injury because of confusion.The patient's gait is stable.To prevent injury to the patient,the best method of restraint if prescribed would be a(n):

Family members who brought a patient to the emergency department after she had fallen in her home are expressing their feelings of guilt.The nurse's most therapeutic response to the family would be:

The 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.The nurse should:

The 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." The nurse's response will be related to the fact that:

The nurse is caring for an older adult patient who has undergone a total hip replacement.To reduce the risk of further injury,the nurse would:

The nurse is aware that many residents in a long-term care facility refuse to wear the hip protector garment and use,as their excuse,that the garment is:

The nurse is aware that the patient at greatest risk for injury from falls is the:

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