Chapter 20: Falls

Chapter 20: Falls

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

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