Question 1

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 2

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 3

The nurse points out that people who have a fear of falling may alter their lifestyle to the point that they: (Select all that apply.)

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 4

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: (Select all that apply.)

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 5

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 6

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 7

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:

Accepted Answer

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. 
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.

Question 8

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 9

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 10

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 11

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 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

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

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 points out that people who have a fear of falling may alter their lifestyle to the point that they: (Select all that apply.)

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: (Select all that apply.)

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

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 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:

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

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:

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

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:

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