Exam 1: Fall Management Questions

Which are extrinsic factors responsible for falls in older adults? Select all that apply. 1. impaired visoin 2. cognitive impairment 3. environmental hazards 4. inappropriate footwear 5. improper use of assistive devices

3, 4, 5 rationale: Environmental hazards, inappropriate foot wear, and improper use of assistive devices are extrinsic factors that are responsible for falls in older adults. Impaired vision and cognitive impairment are intrinsic factors that are responsible for falls in older adults.

A registered nurse (RN) is giving home care instructions to a client who was treated for injuries due to a fall. Which statement made by the client indicates a need for correction? 1. i should walk on scatter rugs at home 2. i should drink 3000 mL of water of every day 3. i should eat fruits and vegetables six times a day 4. i should exercise the joints above and below the cast daily

1 rationale: A client with injuries due to a fall must avoid having throw or scattered rugs at home to reduce the incidence of falls. The registered nurse (RN) should encourage the client to drink 3000 mL of water per day to promote optimal bladder and bowel function. The client should eat six small meals with foods rich in fiber, such as fruits and vegetables, to prevent constipation. The RN has to encourage the client to perform exercise above and below the cast daily for a speedy recovery.

Which intrinsic factors may contribute to falls in older adults? Select all that apply. 1. deconditioning 2. impaired vision 3. inappropriate foot wear 4. improper use of assistive devices 5. unfamiliar environment of hospital room

1, 2 rationale: Falls in older clients may be due to intrinsic factors and extrinsic factors. Deconditioning and impaired vision are intrinsic factors that can lead to falls. Inappropriate foot wear, improper use of assistive devices like walkers, and a lack of familiarity with the hospital room are extrinsic factors.

The nurse is assessing the client with subdural hematoma after a fall. The client was admitted for observation with a normal neurologic assessment on admission. Upon entering the room the nurse finds the client exhibiting seizure activity. Which is the first action the nurse should take? 1. assess the client's airway 2. place pads on the side rails 3. notify the healthcare provider 4. leave and obtain the crash cart

1 rationale: Ensuring an airway is the first action in an emergency response to any client. Placing pads on the side rails during the procedure is too late; protecting the airway and client are priority. The healthcare provider will be notified as soon as the nurse ensures the client's safety and has a patent airway. The nurse should not leave the client during a seizure.

While visiting the hospital, the spouse of a client slips and falls on a recently washed floor in the hallway leading to the client's room. To meet the criteria of ethical practice, what action should the nurse who witnessed the occurrence take? 1. initiate an agency incident report 2. report the fall to the state (provincial) health department 3. write a brief description of the incident to be kept by the nurse manager 4. determine that no documentation is needed because the visitor is not a client in the hospital

1 rationale: Health care agencies document the occurrence of any event out of the ordinary that results in or has the potential to harm a client, employee, or visitor. Falls by visitors are not required to be reported to state (provincial) health departments. However, incident reports are required to be presented to accrediting agencies for review when an agency is in the process of being accredited. Writing a brief description of the incident to be kept by the nurse manager is not a requirement of ethical practice. However, a nurse who is involved in an incident or is a witness to an incident should write an accurate description of the event, along with the names of individuals involved. This documentation should be kept by the nurse at home. Lawsuits may take several years before they come to trial, and personal notes may help the nurse recall the event. The documentation must accurately contain the same elements included in the formal incident report. Taking no action is irresponsible. All events out of the ordinary that result in or have the potential to harm a visitor should be documented in an agency incident report.

An older adult experiencing delirium suffers from a leg fracture caused by a fall. Which interventions should the nurse follow to prevent future falls? Select all that apply. 1. minimizing medications 2. modifying the home environment 3. teaching clients about the safe use of the Internet 4. manage foot and footwear problems 5. providing information about the effects of using alcohol

1, 2, 4 rationale: The nursing interventions followed to prevent falls are minimizing medications, modifying the home environment and managing foot and footwear problems. Teaching clients about the safe use of Internet may be an effective intervention for preventing delirium. Providing information about the effects of using alcohol is not an intervention for older adults; this action is more beneficial for adolescents.

Which intrinsic factor is associated with the fall of an older adult? 1. wet floors 2. poor lighting 3. deconditioning 4. inappropriate footwear

3 rationale: Intrinsic risk factors associated with the fall of an older adult may include deconditioning. Wet floors, poor lighting, and inappropriate footwear are extrinsic risk factors.

A nurse teaches an elderly client safety tip to prevent falls. Which physiologic change may have occurred in the client? 1. slowed movement 2. cartilage degeneration 3. decreased bone density 4. decreased range of motion (ROM)

3 rationale: Teaching safety tips to prevent falls would best help a client with decreased bone density. If a client experiences slow movements, the nurse should not rush the client because the client may become frustrated if hurried. Providing a client with cartilage degeneration with a moist heat source such as a shower or a warm compress is beneficial because this action may increase blood flow to the area. A nurse should assess a client's ability to perform activities of daily living and mobility to help improve the self-care skills of clients with a decreased range of motion.

A nurse working in a postoperative ward assists an older client in getting to the washroom in order to prevent the client from falling. Which level of need did the nurse prioritize in the client according to Maslow's hierarchy of needs? 1. level 1 2. level 2 3. level 3 4. level 4

2 rationale: A nurse who assists an older client in getting to the washroom is fulfilling the safety and security need, which is the second level of need according to Maslow's hierarchy of needs. The first level involves physiological needs such as air, water, and food. Belonging needs such as friendship, social relationships, and sexual love fall under the third level of need. The fourth level of needs encompasses self-esteem needs, which involve self-confidence, usefulness, self-worth and achievement.

A client sustains a back injury after falling 20 feet (6 m). In which position should the nurse place the client? 1. lateral position with a pillow between the knees 2. any position that reduces pain and is comfortable 3. supine position while not allowing the spine to flex 4. sitting position with a pillow placed in the small of the back

3 rationale: When caring for a client with a suspected back injury, the client should be positioned to keep the vertebral column in alignment (back straight) to prevent further spinal cord damage by vertebral (bone) movements. The lateral position with a pillow between the knees is contraindicated, because it may cause the spine to torque. To prevent additional damage to the spinal cord, the vertebral column should be kept horizontal with the spine in alignment. The comfortable position chosen by the client may be contraindicated, because it may not maintain the spine in alignment. The sitting position is contraindicated because it causes the spine to flex, which can precipitate additional injury.

A nurse observes a window washer falling 25 feet (7.6 m) to the ground. The nurse rushes to the scene and determines that the person is in cardiopulmonary arrest. What should the nurse do first? 1. feel for a pulse 2. begin chest compressions 3. leave to call for assistance 4. perform the abdominal thrust maneuver

2 rationale: According to the American Heart Association and Heart and Stroke Foundation of Canada for CPR, the first step is to feel for a pulse after unresponsiveness is established. In this case, it has been established the client has no pulse (cardiopulmonary arrest); therefore chest compressions are initiated. Do not leave the client to call for assistance. The abdominal thrust (Heimlich) maneuver is used to relieve airway obstruction and is not appropriate in this instance.

As a nurse prepares an older adult client for sleep, actions are taken to help reduce the likelihood of a fall during the night. What nursing action is most appropriate when targeting older adults' most frequent cause of falls? 1. moving the client's bedside table closer to the bed 2. encouraging the client to take an available sedative 3. instructing the client to call the nurse before going to the bathroom 4. assisting the client to telephone home to say goodnight to the spouse

3 rationale: Statistics indicate that the most frequent cause of falls by hospitalized clients is getting up or attempting to get up to go to the bathroom unassisted. Although moving the bedside table closer to the bed is helpful in reducing falls because it moves the bedside table closer to the client's center of gravity, it is not the primary intervention to prevent falls. Sedatives contribute to the risk for falls by altering the client's sensorial abilities. Although talking to the spouse may calm the client and contribute to sleep, it does not reduce the incidence of falls.

A client is placed on a stretcher and restrained with straps while being transported to the x-ray department. A strap breaks, and the client falls to the floor, sustaining a fractured arm. Later the client shows the strap to the nurse manager, stating, "See, the strap is worn just at the spot where it snapped." What is the nurse's accountability regarding this incident? 1.exempt from any lawsuit because of the doctrine of respondeat superior 2. totally responsible for the obvious negligence because of failure to report defective equipemnt 3. liable, along with the employer, for misapplication of equipment or use of defective equipment that harms the client 4. exonerated, because only the hospital, as principal employer, is responsible for the quality and maintenance of equipment

3 rationale: Using a stretcher with worn straps is negligent; this oversight does not reflect the actions of a reasonably prudent nurse. The nurse is responsible and must ascertain the adequate functioning of equipment. The hospital shares responsibility for safe, functioning equipment.