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 fo
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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 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 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 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?” 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 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) 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 physician’s 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.
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