02.05 Fall and Injury Prevention

Question 5 of 8 A nurse is filling out a fall risk assessment on a client who is considered to be at high risk of injury due to falls. Which of the following information is documented as part of the fall risk assessment? Alterations in elimination pattern Temperature instability Use of medications that could cause bleeding The presence of infection

Answe A Alterations in elimination pattern The nurse who is caring for a patient who is a fall risk should complete a fall risk assessment on a regular basis according to facility policy. Elements of the fall risk include assessing for medications that could cause drowsiness or sedation and alterations in elimination patterns that cause incontinence, which may require assistance with using the toilet. Use of medications that could cause bleeding Assessment for medications that could cause drowsiness or sedation should be done. Temperature instability Temperature instability will not cause falls. The presence of infection The presence of an infection wouldn't cause an increased fall risk.'

Question 6 of 8 A client is being discharged home after being evaluated for a fall. Which of the following should the nurse include in discharge instructions for the client? Select all that apply. Make sure to have adequate lighting in the home Not using a walker when the doorway isn't wide enough Clear clutter and widen walking pathways in the home Make sure the bottoms of shoes have good traction Place rugs in all walking areas to improve traction

Answer Place rugs in all walking areas to improve traction This action will increase the risk of falls. ✅Make sure to have adequate lighting in the home Fall prevention includes having good lighting to see all walkways, removing all rugs from the house, clearing all clutter in the house, having shoes with good traction, using ambulatory aids properly, and making pathways wider. ✅Make sure the bottoms of shoes have good traction Shoes with good traction reduces the chance of a fall. ✅Clear clutter and widen walking pathways in the home Clutter and narrow walking pathways will increase the risk of falling. Not using a walker when the doorway isn't wide enough his action will increase the risk of falls.

Question 4 of 8 The emergency room has four clients that have had a fall. Which of the following types of falls is the priority for the nurse to see first? Second story roof Off a chair with obvious leg deformity Down 5 stairs On side walk and hit head

Answer A Second story roof A fall from any distance that is 20 feet or greater is considered a level 1 trauma. A fall from the roof is concerning for internal damage that the nurse may not be able to see initially. Down 5 stairs This is a serious fall, but the fall from the second story roof is further, and is the priority. On side walk and hit head This client may or may not have sustained head trauma, but without further information on the client's symptoms, this client would not take priority over the client who fell from the roof. Off a chair with obvious leg deformity This fall should be seen quickly, but the second story roof fall takes priority.

Question 7 of 8 A nurse is working in the surgical unit and is assigned the following clients. Client A, a 78-year-old male client who recently had a hip fracture and who suffers from Parkinson's disease. Client B, a 60-year-old client who is visually impaired and who is post-op day three after hernia surgery. Client C, a 56-year-old client who has a prescription for ketorolac and who had shoulder surgery. In which order would the nurse categorize these patients' fall risk from greatest risk to least risk? C, A, B B, C, A A, C, B A, B, C

Answer D A, B, C The nurse must assess each client's fall risk and care for these clients accordingly. The 78-year-old client with balance issues and a broken hip is the highest fall risk. This is followed by the younger client who is visually impaired. The client with the least fall risk is the client with shoulder surgery and a non-narcotic pain reliever. B, C, A This is the incorrect order in which the client's are at increased risk for falling. See correct rationale for correct order. A, C, B The 78-year-old client with balance issues and a broken hip is the highest fall risk. However, the client with visual impairment is at a greater risk for falls than the client prescribed a non-narcotic pain reliever. See correct rationale for correct order. C, A, B The client prescribed a non-narcotic pain reliever is at the least risk for falls. See correct rationale for correct order.

Question 1 of 8 While admitting a client, the nurse has determined the client is a fall risk. What is a priority nursing intervention? Provide a cane Place a fall risk armband on the client Place a chair by the bedside Provide a walker

Answer b Place a fall risk armband on the client If a client is a fall risk, an armband should be placed on the client right away indicating a fall risk. The armband's purpose is to quickly inform any provider that the client may need additional safety measures and should not get out of bed without a staff member to assist. Provide a walker Not every fall risk can be corrected with an assistive device. Some clients with a fall risk should NOT be given a walker or cane because gait is not the reason for the fall risk. Provide a cane Not every fall risk can be corrected with an assistive device. Some clients with a fall risk should NOT be given a walker or cane because gait is not the reason for the fall risk. Place a chair by the bedside A chair by the bedside could lead to a fall if it is in the way of the client and the client attempts to climb over it. This would not decrease the chance of a fall.

Question 2 of 8 A client who is exhibiting behavioral and psychological symptoms should be medically cleared to rule out which of the following? Ludwig's angina Myocardial infarction Pertussis Head trauma

Answer d Myocardial infarction Clients experiencing an MI would be showing symptoms of pain, nausea, dyspnea, diaphoresis, weakness, palpitations, syncope, and/or feeling of impending doom. A client with an altered mental status should be ruled out for head trauma. Head trauma Clients may present with an altered level of consciousness, altered motor or sensory activity, and anxiety. Clients presenting with behavioral or psychological symptoms must be ruled out for neurological problems before treating them as a mental health client. Ludwig's angina These clients would exhibit swelling in the neck, and face and protrusion of the tongue which can cause difficulty speaking and swallowing. A client with an altered mental status should be ruled out for head trauma. Pertussis Clients would exhibit respiratory symptoms and a persistent cough. A client with an altered mental status should be ruled out for head trauma.

Question 8 of 8 The risk management nurse at a long-term care facility is reviewing the facility's data related to recent client falls. The nurse should consider which of the following as a risk factor for client falls? Select all that apply. Change in mental status Gait disorders Hypertension Age-related vision changes Muscle deconditioning

Answer: A,B, D, E Age-related vision changes Change in mental status Hypertension Muscle deconditioning Gait disorders

Question 3 of 8 A nurse is caring for a 9-year-old client who is considered a fall risk because of a history of seizures. Which of the following interventions should be implemented to prevent falls in a pediatric client? Select all that apply. Keep the client's bed in the lowest position Move furniture and room items so that there is a clear walkway Ensure the client wears an identification bracelet containing the child's name and hospital number Keep personal items out of reach of the child Provide non-slip socks for the client to wear while ambulating

Answer: a, b, e Ensure the client wears an identification bracelet containing the child's name and hospital number While an identification bracelet is a safety measure for identifying the client, it is not a measure to reduce the risk of falls. Keep personal items out of reach of the child Personal items should be kept within reach of the child because if he or she is straining to reach items that are too far away it could cause a fall. ✅Keep the client's bed in the lowest position A pediatric client can be a fall risk depending on their developmental age and health status, just like any client admitted to the hospital. When a child is admitted to the hospital, the nurse should assess the client's fall risk and take precautions to minimize injury. When a client is determined to be a high fall risk, the nurse should ensure that the room is free of clutter and that personal items and the call light are within reach. The bed should remain in the lowest position and the nurse or a caregiver should be with the child during ambulation. The client should wear non-slip socks to prevent slipping on the floor. ✅Provide non-slip socks for the client to wear while ambulating A pediatric client can be a fall risk depending on their developmental age and health status, just like any client admitted to the hospital. When a child is admitted to the hospital, the nurse should assess the client's fall risk and take precautions to minimize injury. When a client is determined to be a high fall risk, the nurse should ensure that the room is free of clutter and that personal items and the call light are within reach. The bed should remain in the lowest position and the nurse or a caregiver should be with the child during ambulation. The client should wear non-slip socks to prevent slipping on the floor. ✅Move furniture and room items so that there is a clear walkway A pediatric client can be a fall risk depending on their developmental age and health status, just like any client admitted to the hospital. When a child is admitted to the hospital, the nurse should assess the client's fall risk and take precautions to minimize injury. When a client is determined to be a high fall risk, the nurse should ensure that the room is free of clutter and that personal items and the call light are within reach. The bed should remain in the lowest position and the nurse or a caregiver should be with the child during ambulation. The client should wear non-slip socks to prevent slipping on the floor.