Chapter 19: Falls and Fall Risk Reduction Touhy: Ebersole & Hess' Toward Healthy Aging, 9th Edition MULTIPLE CHOICE 1. 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. DIF: Cognitive Level: Applying REF: p. 248 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Safety and Infection Control 2. 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. DIF: Cognitive Level: Applying REF: pp. 257–258 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Safety and Infection Control 3. 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
