Ch. 11 & 12 Falls & Immobility/ Med-surg 8th edition

Which recommendation should a nurse make to the family of a patient diagnosed with ataxia when preparing discharge to home?

• Remove all scatter rugs from the home.

• Rearrange the bedroom furniture.

• Arrange for someone to stay with the patient 24 hours a day.

• Purchase oversized shoes so that they are easy to get on.

Which intervention should be first when a nurse finds that a patient has fallen?

• Ask the patient to stand up.

• Document the fall according to agency policy.

• Remove or correct the cause of the fall.

• Assess the circumstances of the fall and any injuries sustained.

Which information should discharge planning for a patient who lives alone and is at high risk for falling include?

• Cannot go home unless someone is with him all the time.

• Must go to a long-term care facility.

• Can wear devices around the neck that can signal for help.

• Needs to be aware of the dangers of living alone.

Which percentage correctly represents total death resulting from falls in older adults?

A nurse is caring for an older adult patient who has undergone a total hip replacement. Which action best reduces the risk of further injury?

• Leave all the lights on in the room at night.

• Leave the side rails down at all times to enable the patient to get to the bathroom quickly.

• Keep the call bell and other frequently used items in easy reach.

• Keep the bed in the high position to discourage the patient from getting out of bed without assistance.

A nurse is talking to the family of a patient who has fallen several times. Which fall-reduction intervention is the most important for the nurse to relay to this family?

• Prevention

• Hospitalization

• Continuous observation

• Restraint

Which time period correctly represents how often a nurse should remove and release restraints when caring for a patient who requires wrist restraints?

• Once every 8 hours for at least 30 minutes

• Once every 4 hours for at least 15 minutes

• Once every 2 hours for at least 10 minutes

• Once every 1 hour for at least 5 minutes

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. 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. Which method of restraint is the best to prevent injury to the patient?

• Geriatric chair

• Ambularm bracelet

• Vest restraint

• Wrist or ankle restraint or both

A nurse is admitting a new patient to the nursing unit. Which information is important for the nurse to ask when conducting the admission assessment to assess the patient’s risk for falling?

• How many times have you fallen before?

• How many hours do you sleep at night?

• What are your eating habits?

• Do you smoke?

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. Which action should the nurse implement?

• Never leave the patient alone in his room.

• Ask the patient if he could use the bedside commode instead of going to the bathroom.

• Make suicidal precautions part of the care plan.

• Ask the patient to sit on the side of the bed for a minute or two before standing and then stand slowly.