Chapter 20: Falls Nursing School Test Banks

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.
ANS: A
Scatter rugs can slip and cause a patient to fall.

DIF: Cognitive Level: Application REF: p. 320 OBJ: 5
TOP: Fall Prevention KEY: Nursing Process Step: Planning
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

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.
ANS: D
The first implementation should be to assess what happened, determine whether any injuries have occurred, and then document and correct the cause.

DIF: Cognitive Level: Application REF: p. 321-322 OBJ: 6
TOP: Implementations for a Fall KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

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
ANS: C
A person who is at risk for falling would be wise to have a call system to obtain help from others. Devices worn around the neck that can send signals to a control center are effective and provide a feeling of well-being for the individual who has the potential for falling.

DIF: Cognitive Level: Comprehension REF: p. 322 OBJ: 5
TOP: Implementations for a Fall KEY: Nursing Process Step: Planning
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

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%
ANS: D
Older adults constitute only 12% to 13% of the total U.S. population, but they account for 72% of the total deaths resulting from falls.

DIF: Cognitive Level: Knowledge REF: p. 315 OBJ: 2
TOP: Incidence of Falls KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

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.
ANS: C
Keeping the call bell and other frequently used items within easy reach will prevent the patient from having to reach, which increases the risk for falling.

DIF: Cognitive Level: Application REF: p. 318 | p. 321
OBJ: 5 TOP: Fall Prevention
KEY: Nursing Process Step: Planning
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

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
ANS: A
The most important implementation for falls is prevention. The best prevention is education that is aimed toward minimizing intrinsic and extrinsic factors.

DIF: Cognitive Level: Comprehension REF: p. 318 OBJ: 5
TOP: Fall Prevention KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Safety and Infection Control

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
ANS: C
Physical restraints must be removed and released every 2 hours for 10 minutes. In addition, they should be frequently checked to ensure that the restraint is properly used and is providing adequate protection and comfort without impeding circulation or breathing.

DIF: Cognitive Level: Knowledge REF: p. 317 OBJ: 4
TOP: Physical Restraints KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

8. An older adult patient in a long-term care facility is at risk for injury because of confusion. The patients 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
ANS: B
If a physical restraint is used, the least restrictive device is best. This patient has a stable gait, so the alarm bracelet allows the patient to move about freely while preventing him from leaving the premises.

DIF: Cognitive Level: Knowledge REF: p. 317-318 OBJ: 4
TOP: Physical Restraints KEY: Nursing Process Step: Planning
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

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 patients 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?
ANS: A
People who are at the greatest risk for falls and injury are those who have fallen before.

DIF: Cognitive Level: Application REF: p. 318 OBJ: 3
TOP: Fall Prevention KEY: Nursing Process Step: Assessment
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

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.
ANS: D
Psychotropic drugs, such as antidepressants, commonly cause orthostatic hypotension. The patient should sit on the side of the bed and then stand slowly to prevent falling.

DIF: Cognitive Level: Application REF: p. 318 OBJ: 3
TOP: Chemical Restraints KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

11. In reviewing a patients 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)
ANS: B
Alprazolam (Xanax) is a psychotropic drug used as a chemical restraint.

DIF: Cognitive Level: Knowledge REF: p. 318 OBJ: 4
TOP: Chemical Restraints KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

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.
ANS: B
A physicians order is required for restraint use, and the order must specify the duration and circumstances under which the restraint may be used.

DIF: Cognitive Level: Application REF: p. 316 OBJ: 4
TOP: Physical Restraints KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

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.
ANS: B
The patient should begin ambulating as soon after a fall as possible to prevent the hazards of bed rest and to restore confidence. Applying restraints after a fall is tempting, but avoiding their use, if possible, is best.

DIF: Cognitive Level: Application REF: p. 321-322 OBJ: 6
TOP: Implementations for a Fall KEY: Nursing Process Step: Planning
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation

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
ANS: A
Definitions of falls vary, but a fall is an unintentional event that is unrelated to medication or loss of consciousness and that results in injury.

DIF: Cognitive Level: Knowledge REF: p. 315 OBJ: 1
TOP: Falls KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

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
ANS: D
Intrinsic factors are related to the functioning of the individual (e.g., aging process, physical illness). Extrinsic factors are related to the environment.

DIF: Cognitive Level: Knowledge REF: p. 318-319 OBJ: 2
TOP: Incidence of Falls KEY: Nursing Process Step: Assessment
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

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.
ANS: C
The only people who are considered restrainable are those who (1) are at high risk for a fall that is life threatening; (2) need postural support for safety, comfort, or both; (3) may be a serious hazard to themselves, objects, or others; and (4) have life-threatening medical symptoms and for whom a restraint may be temporarily used to provide necessary treatment.

DIF: Cognitive Level: Comprehension REF: p. 316 OBJ: 4
TOP: Restraints KEY: Nursing Process Step: Planning
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care

17. Which patient population patient is at greatest risk for injury from falls?
a. Toddler
b. Teenager
c. Middle-aged adult
d. Older adult
ANS: D
Older adults are at particular risk for accidents because of changes brought about by aging, a greater potential for injury, and poorer clinical outcomes.

DIF: Cognitive Level: Comprehension REF: p. 315 OBJ: 3
TOP: Risk of Falls KEY: Nursing Process Step: Analysis
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

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 patients left side
b. In the patients bathroom
c. In the patients closet
d. On the patients right side
ANS: D
The unaffected side and within reach. This placement reduces the risk of falling.

DIF: Cognitive Level: Application REF: p. 318-319 OBJ: 5
TOP: Fall Prevention KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Safety and Infection Control

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.
ANS: B
The patient who is at risk for falls must have rails to hold to prevent falling. A rubber mat in the shower and rubber-soled shoes are important to prevent slipping. Moderate exercise is beneficial.

DIF: Cognitive Level: Comprehension REF: p. 320 OBJ: 5
TOP: Fall Prevention KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Safety and Infection Control

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.
ANS: C
The get up and go technique of evaluation requires that the resident be able to sit and rise from an armless chair.

DIF: Cognitive Level: Comprehension REF: p. 318 | p. 320
OBJ: 5 TOP: Fall Prevention
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

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 doesnt get hurt much. To which fact should the nurses response relate?
a. Falls are the most frequent cause of accidental injury and death among older adults.
b. Worrying is probably unnecessary because she hasnt been hurt in the past.
c. Falls usually occur in institutional settings.
d. Falls by older adults are not preventable.
ANS: A
The risk of injury from falls is highest in people older than 65 years, and falls are the most frequent cause of accidental injury and death among older adults. Older adults account for 72% of total deaths resulting from falls.

DIF: Cognitive Level: Comprehension REF: p. 315 OBJ: 2
TOP: Incidence of Falls KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

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
ANS: B
The patient with Parkinson disease has a very unsteady shuffling gait, as well as a very slow response, which could cause the patient to fall.

DIF: Cognitive Level: Comprehension REF: p. 316 OBJ: 3
TOP: Risk of Falls KEY: Nursing Process Step: Assessment
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

23. A nurse visiting a patient in the patients 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.
ANS: B
Slick floors can cause the patient to slip and fall. The other choices are implementations that will help reduce the risk of falls.

DIF: Cognitive Level: Comprehension REF: p. 316 OBJ: 3
TOP: Fall Prevention KEY: Nursing Process Step: Planning
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

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.
ANS: A
The last step of the shuffle method is to stand up.

DIF: Cognitive Level: Application REF: p. 322 OBJ: 6
TOP: Getting Up after a Fall KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Safety and Infection Control

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. Dont worry. You have nothing to feel guilty about.
d. I can see you are worried.
ANS: D
This choice presents therapeutic communication and uses the technique of clarifying.

DIF: Cognitive Level: Application REF: p. 322 OBJ: 6
TOP: When a Fall Occurs KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation

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.
ANS: A
Residents resist wearing the hip protector garment because it is uncomfortable.

DIF: Cognitive Level: Knowledge REF: p. 321 OBJ: 3
TOP: Hip Protector Garment KEY: Nursing Process Step: Planning
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

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.
ANS: B
All techniques for rising after a fall rely on pulling up on sturdy furniture.

DIF: Cognitive Level: Comprehension REF: p. 322 OBJ: 6
TOP: Rising after a Fall KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

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
ANS: A
Mittens are the lesser of restraints that will hinder the patient from removing the feeding tube.

DIF: Cognitive Level: Knowledge REF: p. 316 OBJ: 7
TOP: Restraints KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

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
ANS: A, B, C, D
Restricting physical and social activities, becoming more dependent, and having an increased need for residency in a long-term-care facility all have to do with an altered lifestyle. The development of depression is not a lifestyle alteration but may be a result of the lifestyle change.

DIF: Cognitive Level: Comprehension REF: p. 315 OBJ: 3
TOP: Fear of Falls KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation

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
ANS: A, E
Diminished vision and generalized weakness are the only options related to the individual that cannot be changed (intrinsic). The other options are related to the environment and can be changed (extrinsic).

DIF: Cognitive Level: Comprehension REF: p. 315-316 OBJ: 5
TOP: Intrinsic Factors KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Safety and Infection Control

COMPLETION

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

ANS:
fracture
According to reported falls, only 1% to 5% result in a fracture.

DIF: Cognitive Level: Knowledge REF: p. 316 OBJ: 2
TOP: Incidence KEY: Nursing Process Step: N/A MSC: NCLEX: N/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 _____.

ANS:
sideways
Rotation maneuvers can be taught to patients to help them avoid falling sideways.

DIF: Cognitive Level: Knowledge REF: p. 321 OBJ: 5
TOP: Fall Prevention KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Coordinated Care

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

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

DIF: Cognitive Level: Knowledge REF: p. 320 OBJ: 9
TOP: Tai Chi KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

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