NUR 3480 Med Surg Exam 1 UPDATED
ACTUAL QUESTIONS AND CORRECT
ANSWERS
What is the #1 priority at all times for nurses? - correct answer safety
Why are falls dangerous? - correct answer they are devastating and can cause life-threatening
injuries
What is an important indicator for a future fall? - correct answer having fallen previously
What should nurses ask patients to determine if they should do a quick assessment? - correct
answer "have you fallen before?"
What do the points on a fall risk assessment mean? - correct answer the interventions that
should be needed
What is a question that nurses should ask patients during a fall risk assessment? - correct
answer "what kind of fall did you have?"
What is a mental related issue that should be determined during a fall risk assessment? - correct
answer confusion
What are things that may increase risk for falls? - correct answer lower extremity muscle
weakness
Gait or balance deficit
Mobility impairment
Restraint use
,Use of an assistive device
Presence of intravenous therapy
Impaired adls
Age older than 75 years
Altered elimination
History of falls
Administration of high-risk drugs (narcotics, antiepileptics, bezodiazepines)
Use of 4 or more medications
Depression
Visual deficit
Arthritis
History of cerebrovascular accident
Cognitive impairment
Secondary diagnosis/chronic disease
What are nurses responsible for in terms of falls? - correct answer identifying at risk patients
Putting interventions into place
,When do most falls occur? - correct answer while toileting
On the way to the bathroom
While in the bathroom
On the way back from the bathroom
What happens when patients hit their heads on the floor or ceramic sink or toilet? - correct
answer serious injuries result
What should a nurse check during a fall risk assessment? - correct answer room/environment
Loose rugs
Lowest position of bed
Lighting
When can patients' risk for falls change? - correct answer hour to hour
Day to day
What are the primary fall causes? - correct answer confusion
Depression
Environment
Medications
, Change in balance or gait disturbance
Muscle weakness
Dizziness, syncope, and vertigo
Cardiovascular changes (postural/orthostatic hypotension)
Change in vision or vision impairment
Physical environment/environmental hazards
Acute illness
Neurological disease (dementia, depression)
Language disorders that impair communication
Polypharmacy
What patients are not picked up after a fall? - correct answer spinal cord injury patients
What are nursing diagnoses for falls? - correct answer risk of falls
Risk of injury
Impaired physical mobility
What are some fall interventions? - correct answer follow hospital policy
ACTUAL QUESTIONS AND CORRECT
ANSWERS
What is the #1 priority at all times for nurses? - correct answer safety
Why are falls dangerous? - correct answer they are devastating and can cause life-threatening
injuries
What is an important indicator for a future fall? - correct answer having fallen previously
What should nurses ask patients to determine if they should do a quick assessment? - correct
answer "have you fallen before?"
What do the points on a fall risk assessment mean? - correct answer the interventions that
should be needed
What is a question that nurses should ask patients during a fall risk assessment? - correct
answer "what kind of fall did you have?"
What is a mental related issue that should be determined during a fall risk assessment? - correct
answer confusion
What are things that may increase risk for falls? - correct answer lower extremity muscle
weakness
Gait or balance deficit
Mobility impairment
Restraint use
,Use of an assistive device
Presence of intravenous therapy
Impaired adls
Age older than 75 years
Altered elimination
History of falls
Administration of high-risk drugs (narcotics, antiepileptics, bezodiazepines)
Use of 4 or more medications
Depression
Visual deficit
Arthritis
History of cerebrovascular accident
Cognitive impairment
Secondary diagnosis/chronic disease
What are nurses responsible for in terms of falls? - correct answer identifying at risk patients
Putting interventions into place
,When do most falls occur? - correct answer while toileting
On the way to the bathroom
While in the bathroom
On the way back from the bathroom
What happens when patients hit their heads on the floor or ceramic sink or toilet? - correct
answer serious injuries result
What should a nurse check during a fall risk assessment? - correct answer room/environment
Loose rugs
Lowest position of bed
Lighting
When can patients' risk for falls change? - correct answer hour to hour
Day to day
What are the primary fall causes? - correct answer confusion
Depression
Environment
Medications
, Change in balance or gait disturbance
Muscle weakness
Dizziness, syncope, and vertigo
Cardiovascular changes (postural/orthostatic hypotension)
Change in vision or vision impairment
Physical environment/environmental hazards
Acute illness
Neurological disease (dementia, depression)
Language disorders that impair communication
Polypharmacy
What patients are not picked up after a fall? - correct answer spinal cord injury patients
What are nursing diagnoses for falls? - correct answer risk of falls
Risk of injury
Impaired physical mobility
What are some fall interventions? - correct answer follow hospital policy
