Exam 2: Chapter 19 Flashcards
Which attempt by the family to prevent an older, frail adult from falling causes the home
health nurse concern?
a. Keeping several low wattage night-lights on in the evening
b. Installing wooden railings on the stairway to the bathroom
c. Keeping the side rails up on the client’s bed at night
d. Encouraging the client to use a cane when ambulating
ANS: C
Keeping side rails up have proven to be a risk factor for falls rather than a positive
intervention. The remaining interventions are appropriate and generally effective.
An 88-year-old woman is admitted to the hospital with a diagnosis of pneumonia. She has a
history of hypertension and congestive heart failure and is on a total of five different
medications for these chronic conditions. The nurse caring for the woman develops a care
plan that includes the diagnosis Risk for Falls. A priority nursing intervention for this client is to:
a. perform a fall assessment.
b. keep all of the side rails up on the client’s bed at nighttime.
c. place the client on bed rest so that she does not fall.
d. assess the client’s dietary intake for calcium adequacy.
ANS: A
Completing a fall assessment will enable the nurse to identify and correct the risk factors for
this patient. Side rails have not been found to be effective in keeping a client in bed and may
actually lead to injury. Maintaining a patient on bed rest can lead to deconditioning and
actually contribute to falls. Assessing the client’s dietary intake of calcium is a good
intervention for this age group, but it is not a priority and will not prevent falls.
A nurse is assessing an older adult’s risk for falls. One of the questions that she asks is whether the older adult has fallen in the past year. She asks this because individuals who have fallen:
a. have a higher risk of falling again than persons who did not fall in the past year.
b. are more likely to sustain injuries if they fall again than persons who did not fall in
the past year.
c. have most likely developed a fear of falling as compared to persons who did not
fall in the past year.
d. are most likely to have a balance disorder as compared to persons who did not fall in the past year.
ANS: A
A history of falls is an important risk factor and individuals who have fallen have three times
the risk of falling again than persons who did not fall in the past year. There is no evidence to support the other three options.
A nurse is admitting and orienting an older adult to the hospital unit. She discusses fall
prevention and demonstrates the use of the call bell to the patient. The patient’s daughter asks: “Why don’t you just put up all the side rails to prevent my mother from getting out of bed by
herself and falling. That should work, right?” The best response by the nurse is:
a. “Side rails have only proven to be effective in decreasing falls in patients who
have already fallen.”
b. “There is no evidence that side rail use decreases falls, and in fact there is a greater
risk of injury.”
c. “Side rails are only effective when used with patients who have dementia.”
d. “Side rails do not decrease falls, but they do decrease fall-related injuries.”
ANS: B
There is no evidence to date that side rail use decreases the risk or rate of fall occurrence.
There are numerous reports and studies documenting the negative effects of side rail use, including entrapment deaths and injuries that occur when the person slips through the side rail bars or between split side rails, the side rail and the mattress, or between the head or footboard, side rail, the mattress , or between the head or footboard, side rail, and mattress.
A nurse in a long-term care facility notes that there has been an increase in falls on one unit and that many of the falls are occurring immediately following mealtime. The nurse recommends that the nursing home conduct a trial of six smaller meals instead of the three
traditional meals. The nurse makes this recommendation on the understanding that:
a. postural changes in blood pressure are common in older adults and frequently
occur around mealtimes.
b. postprandial hypotension occurs after ingestion of a carbohydrate meal and may be
related to the release of a vasodilatory peptide.
c. residents of long term care facilities are often on many different medications,
which are given at mealtimes.
d. it is common practice to take long term care residents to the bathroom immediately
following meals.
ANS: B
Postprandial hypotension occurs after ingestion of a carbohydrate meal and may be related to the release of a vasodilatory peptide. Modifications such as increased water intake before eating or substituting six smaller meals daily for three larger meals may be effective.
Orthostatic hypotension is a cause of falls in older adults, but does not just occur around meal
times. While it is true that residents of long term care facilities are on multiple medications and are usually toileted following meals, neither of these options addresses postprandial
hypotension.
Which assessment finding is a contributor to an older client’s risk for falls? (Select all that
apply. )
a. Client is awaiting cataract surgery on right eye.
b. Client’s type 2 diabetes is poorly controlled with diet and exercise alone.
c. Client reports a fall in the last year.
d. Client has a history of contact dermatitis and psoriasis.
e. Client attends Tai Chi classes at the senior center.
ANS: A, B, C
The correct options are those that affect the client’s vision, presence of factors affecting sensations in the legs and feet, and a history of falls. There is no research to connect the risk
of falls with either of the skin conditions mentioned. Tai Chi improves balance, which
decreases risk of falls.
A home health nurse is making a home visit to an older patient. A nurse conducts a home
safety assessment and screens the environment for potential hazards for falls. Which of the
following are hazards in the home? (Select all that apply.)
a. The absence of railings on the stairway
b. Night-lights in all rooms
c. Clutter throughout the home
d. A small throw rug outside of the shower stall
e. Grab bars in bathroom beside toilet
ANS: A, C, D
The absence of railings on stairway, clutter, and throw rugs can all contribute to falls in the home. Night-lights are recommended to prevent falls as are grab bars positioned beside the
toilet in the bathroom.
A group of older women in an assisted living facility are talking about one of the residents who fell and fractured her hip. The women ask a nurse the following: “It seems like so many of us fall and break our hips, and then it is downhill from there. Is this really true?” In formulating a response, the nurse considers which of the following? (Select all that apply.)
a. Hip fractures are a leading cause of hospitalization for older people.
b. The major cause of hip fractures is falls.
c. Women have significantly higher mortality rates from hip fractures than do men.
d. Nearly all older patients who sustain a hip fracture will regain prefracture mobility
status within 1 year.
e. Hip fractures are associated with very high morbidity and mortality.
ANS: A, B, E
Hip fracture is the second leading cause of hospitalization for older people. More than 95% of
hip fractures among older adults are caused by falls. Older adults who fracture a hip have a five to eight times increased risk of mortality during the first 3 months after hip fracture. This
excess mortality persists for 10 years after the fracture and is higher in men. Only 50-60% of patients with hip fractures will recover their prefracture ambulation abilities in the first year
postfracture. Most research on hip fractures has been conducted with older women.
A homecare nurse visits a client in the home to conduct a fall risk assessment. The nurse
assesses the client and the home for extrinsic risk factors for falls. Which of the following are
extrinsic risk factors? (Select all that apply.)
a. The client has an unsteady gait.
b. The client uses a cane, but the cane is not the appropriate size for the client.
c. The client’s home is cluttered.
d. The client is on two different medications that cause orthostatic hypotension.
e. There are no grab bars in the client’s bathroom.
ANS: B, C, E
Extrinsic risk factors are external to the patient and related to the physical environment and
include inadequate support devices. Options B, C, and E are extrinsic risk factors. Intrinsic risk factors are unique to each patient. Options A and D are intrinsic risk factors.
A home health nurse is making a home visit to an older patient. A nurse conducts a home
safety assessment and screens the environment for potential hazards for falls. The nurse
recommends that the patient eliminate which of the following? (Select all that apply.)
a. Night-lights
b. Railings on the stairway
c. Loose carpeting on the floors
d. The use of a cane
e. Excess clutter
ANS: C, E
Extrinsic risk factors are external to the patient and related to the physical environment and
include lack of support equipment by bathtubs and toilets, height of beds, condition of floors,
poor lighting, inappropriate footwear, and improper use of or inadequate assistive devices. Nightlights, railings on the stairway, and the use of a cane are all measures that can ameliorate some extrinsic risk factors.
Which one of the following is a true statement about mobility and safety for older adults?
a. Use of restraints on older patients helps prevent injuries from falls.
b. Falls that do not cause physical injury are not significant.
c. The get-up-and-go test provides a measure of a patient’s energy and initiative.
d. Lowering the bed and fluorescent tapes are interventions to increase safety.
D
The overall temperature in your unit is 62° F during the evening shift. In documenting this concern to the administration, which factor is the most important for the health and well-being of older adults?
a. It is not fair for older adults to have to deal with an uncomfortable environment.
b. Some of the residents are wearing blankets around their shoulders to keep warm.
c. An ambient temperature of 62° F is unsuitable for older people because they have impaired thermoregulation.
d. It feels much warmer in the administration wing than out in the patient care areas.
C
The health care provider has not ordered the use of a restraint for an alert patient at high risk for falling. The nurse should implement which side rail use?
a. Two full-length rails
b. One ½-length rail
c. No side rails
d. Four ½-length rails
D
Which of the following describes the nurse’s role for an older patient with a chronic illness?
a. Implement an individualized therapeutic regimen that brings about a cure.
b. Provide caring to help the patient live at the optimal level of health and wellness.
c. Suggest that the patient accept eventual death to reduce the burdens on the patient’s family.
d. Encourage the patient to minimize the use of services to control costs.
B
An older woman has severe osteoporosis in the long bones, impaired mobility, and chronic pain. Which acute illness or condition is this woman most likely to experience as a result of osteoporosis?
a. Peripheral neuropathy
b. Depression
c. Intertrochanteric fracture
d. Opioid analgesic addiction
B
