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 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.

DIF: Cognitive Level: Remembering REF: p. 248

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Safety and Infection Control

4. 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.

DIF: Cognitive Level: Applying REF: p. 258

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Safety and Infection Control

5. 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.

DIF: Cognitive Level: Analyzing REF: p. 251

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Safety and Infection Control

Multiple Response

1. 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.

DIF: Cognitive Level: Applying REF: p. 253

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Safety and Infection Control 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

2. 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.)

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.

DIF: Cognitive Level: Applying REF: p. 248, Box 19-7

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Safety and Infection Control 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.

3. 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.)

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.

DIF: Cognitive Level: Remembering REF: p. 245, Box 19-1

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Safety and Infection Control 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.

4. 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.)

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.

DIF: Cognitive Level: Applying REF: p. 248

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Safety and Infection Control a. Night-lights b. Railings on the stairway c. Loose carpeting on the floors d. The use of a cane e. Excess clutter

5. 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.)

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.

DIF: Cognitive Level: Applying REF: p. 248

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Safety and Infection Control