Chapter 20: Falls
Linton: Introduction to Medical-Surgical Nursing, 6th Edition
MULTIPLE CHOICE
1. 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.
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.
3. 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
4. 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%
5. 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.
6. A nurse is talking to the family of a patient who has fallen several times. What should be the
most important intervention for preventing falls for the nurse to relay to this family?
a.
Prevention
b.
Hospitalization
c.
Continuous observation
d.
Restraint
7. 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
8. 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
9. 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?”
10. 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.
11. 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)
12. 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.
13. 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.
14. 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
15. 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
16. 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.
17. Which patient population patient is at greatest risk for injury from falls?
a.
Toddler
b.
Teenager
c.
Middle-aged adult
d.
Older adult
18. 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
19. 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.
20. 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.
21. 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.
22. What increases the risk of falling for a patient diagnosed with Parkinson disease?
a.
Quick movements
b.
Unsteady, shuffling gait
c.
Hemiparesis
d.
Frequent loss of consciousness
23. 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.
24. 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.
25. Family members who brought a patient to the emergency department after she had fallen in
her home are expressing their feelings of guilt. What is the most therapeutic nursing response?
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.”
26. 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.
27. 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.
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
MULTIPLE RESPONSE
29. 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
30. 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
COMPLETION
31. A nurse is aware that of all the reported falls in the United States, only 1% to 5% result in a
_____.
32. 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 _____.
33. A nurse suggests that a resident who is at risk for falling come to the _____ class to improve
balance.