NYU ADULT AND ELDER 1 EVALUATION EXAM QUESTIONS
AND SOLUTIONS RATED A+
✔✔The nurse found a 68-year-old female patient wandering in the hall. The patient says
she is looking for the bathroom. Which interventions are appropriate to ensure the
safety of the patient? (Select all that apply.)
A. Insert a urinary catheter.
B. Leave a night light on in the bathroom.
C. Ask the physician to order a restraint.
D. Keep the bed in low position with upper and lower side rails up.
E. Assign a staff member to stay with the patient.
F. Provide scheduled toileting during the night shift.
G. Keep the pathway from the bed to the bathroom clear. - ✔✔B,F,G
Older adults in an unfamiliar environment may become confused. A night light may be
beneficial for safety and orientation. Toileting is a common reason for a patient
attempting to get out of bed. Placing the patient on a routine toileting schedule should
help decrease this risk factor. Hospital environments can quickly become cluttered with
equipment, personal items, and other things that create a hazard for falling. Keep
pathways clear. All alternatives should be tried and considered before using a restraint.
Restraint should not be an initial response. The bed should be kept in a low position.
Upper side rails may be used; however, the addition of lower side rails can increase the
risk of injury. The use of side rails alone for a disoriented patient may cause more
confusion and further injury. A confused patient who is determined to get out of bed
attempts to climb over the side rail or climbs out at the foot of the bed. Either attempt
usually results in a fall or injury.
✔✔The family of a patient who is confused and ambulatory insists that all four side rails
be up when the patient is alone. What is the best action to take in this situation? (Select
all that apply.)
A. Contact the nursing supervisor.
B. Restrict the family's visiting privileges.
C. Ask the family to stay with the patient.
D. Inform the family of the risks associated with side-rail use.
E. Thank the family for being conscientious and put the four rails up.
F. Discuss alternatives with the family that are appropriate for this patient. - ✔✔D,F
The family is concerned about ensuring a safe environment for their loved one. The
nurse should discuss their concerns, the risk of using restraints related to using four
side rails, and safer alternatives such as the presences of a family member. If the family
still insists on use of four side rails, you could contact the nursing supervisor to further
discuss the situation with them. This is not a reason to restrict visitation; but, although
you should appreciate their concern, the use of four side rails should be avoided.
, ✔✔A 62-year-old woman is being discharged home with her husband after surgery for a
hip fracture from a fall at home. When providing discharge teaching about home safety
to this patient and her husband, the nurse knows that:
A. A safe environment promotes patient activity.
B. Assessment focuses on environmental factors only.
C. Teaching home safety is difficult to do in the hospital setting.
D. Most accidents in the older adult are caused by lifestyle factors. - ✔✔A
Older adults are frequently fearful of falling and thus often limit activity. A safe
environment, which decreases the risk of a fall, promotes patient activity.
✔✔The nursing assessment of an 80-year-old patient who demonstrates some
confusion but no anxiety reveals that the patient is a fall risk because she continues to
get out of bed without help despite frequent reminders. The initial nursing intervention to
prevent falls for this patient is to:
A. Place a bed alarm device on the bed.
B. Place the patient in a belt restraint.
C. Provide one-on-one observation of the patient.
D. Apply wrist restraints. - ✔✔A
Consider and implement alternatives as appropriate before the use of a restraint. A bed
alarm is an alternative that the nurse implements independently.
✔✔How does the nurse support a culture of safety? (Select all that apply.)
A. Completing incident reports when appropriate
B. Completing incident reports for a near miss
C. Communicating product concerns to an immediate supervisor
D. Identifying the person responsible for an incident - ✔✔A, B, C
Completing incident reports for actual and near-miss events helps the facility track
information and identify trends and patterns that need to be addressed. Communicating
product concerns to a responsible supervisor allows the facility to further investigate and
determine if additional action is required.
✔✔You are admitting Mr. Jones, a 64-year-old patient who had a right hemisphere
stroke and a recent fall. The wife stated that he has a history of high blood pressure,
which is controlled by an antihypertensive and a diuretic. Currently he exhibits left sided
neglect and problems with spatial and perceptual abilities and is impulsive. He has
moderate left-sided weakness that requires the assistance of two and the use of a gait
belt to transfer to a chair. He currently has an intravenous (IV) line and a urinary
catheter in place. What factors increase his fall risk at this time? (Select all that apply.)
AND SOLUTIONS RATED A+
✔✔The nurse found a 68-year-old female patient wandering in the hall. The patient says
she is looking for the bathroom. Which interventions are appropriate to ensure the
safety of the patient? (Select all that apply.)
A. Insert a urinary catheter.
B. Leave a night light on in the bathroom.
C. Ask the physician to order a restraint.
D. Keep the bed in low position with upper and lower side rails up.
E. Assign a staff member to stay with the patient.
F. Provide scheduled toileting during the night shift.
G. Keep the pathway from the bed to the bathroom clear. - ✔✔B,F,G
Older adults in an unfamiliar environment may become confused. A night light may be
beneficial for safety and orientation. Toileting is a common reason for a patient
attempting to get out of bed. Placing the patient on a routine toileting schedule should
help decrease this risk factor. Hospital environments can quickly become cluttered with
equipment, personal items, and other things that create a hazard for falling. Keep
pathways clear. All alternatives should be tried and considered before using a restraint.
Restraint should not be an initial response. The bed should be kept in a low position.
Upper side rails may be used; however, the addition of lower side rails can increase the
risk of injury. The use of side rails alone for a disoriented patient may cause more
confusion and further injury. A confused patient who is determined to get out of bed
attempts to climb over the side rail or climbs out at the foot of the bed. Either attempt
usually results in a fall or injury.
✔✔The family of a patient who is confused and ambulatory insists that all four side rails
be up when the patient is alone. What is the best action to take in this situation? (Select
all that apply.)
A. Contact the nursing supervisor.
B. Restrict the family's visiting privileges.
C. Ask the family to stay with the patient.
D. Inform the family of the risks associated with side-rail use.
E. Thank the family for being conscientious and put the four rails up.
F. Discuss alternatives with the family that are appropriate for this patient. - ✔✔D,F
The family is concerned about ensuring a safe environment for their loved one. The
nurse should discuss their concerns, the risk of using restraints related to using four
side rails, and safer alternatives such as the presences of a family member. If the family
still insists on use of four side rails, you could contact the nursing supervisor to further
discuss the situation with them. This is not a reason to restrict visitation; but, although
you should appreciate their concern, the use of four side rails should be avoided.
, ✔✔A 62-year-old woman is being discharged home with her husband after surgery for a
hip fracture from a fall at home. When providing discharge teaching about home safety
to this patient and her husband, the nurse knows that:
A. A safe environment promotes patient activity.
B. Assessment focuses on environmental factors only.
C. Teaching home safety is difficult to do in the hospital setting.
D. Most accidents in the older adult are caused by lifestyle factors. - ✔✔A
Older adults are frequently fearful of falling and thus often limit activity. A safe
environment, which decreases the risk of a fall, promotes patient activity.
✔✔The nursing assessment of an 80-year-old patient who demonstrates some
confusion but no anxiety reveals that the patient is a fall risk because she continues to
get out of bed without help despite frequent reminders. The initial nursing intervention to
prevent falls for this patient is to:
A. Place a bed alarm device on the bed.
B. Place the patient in a belt restraint.
C. Provide one-on-one observation of the patient.
D. Apply wrist restraints. - ✔✔A
Consider and implement alternatives as appropriate before the use of a restraint. A bed
alarm is an alternative that the nurse implements independently.
✔✔How does the nurse support a culture of safety? (Select all that apply.)
A. Completing incident reports when appropriate
B. Completing incident reports for a near miss
C. Communicating product concerns to an immediate supervisor
D. Identifying the person responsible for an incident - ✔✔A, B, C
Completing incident reports for actual and near-miss events helps the facility track
information and identify trends and patterns that need to be addressed. Communicating
product concerns to a responsible supervisor allows the facility to further investigate and
determine if additional action is required.
✔✔You are admitting Mr. Jones, a 64-year-old patient who had a right hemisphere
stroke and a recent fall. The wife stated that he has a history of high blood pressure,
which is controlled by an antihypertensive and a diuretic. Currently he exhibits left sided
neglect and problems with spatial and perceptual abilities and is impulsive. He has
moderate left-sided weakness that requires the assistance of two and the use of a gait
belt to transfer to a chair. He currently has an intravenous (IV) line and a urinary
catheter in place. What factors increase his fall risk at this time? (Select all that apply.)
