Question 1

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

Accepted Answer

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. A, B, C, D

Question 2

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

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. C

Question 3

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?

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. C

Question 4

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?

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.

Question 5

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?

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.

Question 6

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?

Accepted Answer

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

Question 7

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.)

Accepted Answer

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

Question 8

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?

Accepted Answer

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

Question 9

Which unexpected circumstance best defines a fall?

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

Question 10

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

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.

Question 11

Where should a 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

Question 12

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?

Accepted Answer

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 13

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 _______.

Accepted Answer

The answer of A nurse helps the physical therapist teach...

Question 14

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?

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.

Question 15

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

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.

Question 16

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?

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.

Question 17

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

Accepted Answer

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 18

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

Accepted Answer

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

Question 19

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

Accepted Answer

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

Question 20

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

Accepted Answer

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

Exam 11: Falls