NR 443 Chapter 20: Falls
Chapter 20: Falls
Linton: Introduction to Medical-Surgical Nursing, 6th Edition
MULTIPLE CHOICE
1. What recommendation should a nurse make to the family of a patient diagnosed with
ataxia when preparing discharge to home?
a. Remove all scatter rugs from the home.
b. Rearrange the bedroom furniture.
c. Arrange for someone to stay with the patient 24 hours a day.
d. Purchase oversized shoes so that they are easy to get on.
ANS: A
Scatter rugs can slip and cause a patient to fall.
DIF: Cognitive Level: Application REF: p. 320 OBJ: 5
TOP: Fall Prevention KEY: Nursing Process Step: Planning
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
2. What should be the first intervention when a nurse finds that a patient has fallen?
a. Ask the patient to stand up.
b. Document the fall according to agency policy.
c. Remove or correct the cause of the fall.
d. Assess the circumstances of the fall and any injuries sustained.
ANS: D
The first implementation should be to assess what happened, determine whether any
injuries have occurred, and then document and correct the cause.
DIF: Cognitive Level: Application REF: p. 321-322 OBJ: 6
TOP: Implementations for a Fall KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
3. What should discharge planning for a patient who lives alone and is at high risk for falling
include?
a. Cannot go home unless someone is with him all the time
b. Must go to a long-term care facility
c. Can wear devices around the neck that can signal for help
d. Needs to be aware of the dangers of living alone
ANS: C
A person who is at risk for falling would be wise to have a call system to obtain help from
others. Devices worn around the neck that can send signals to a control center are effective
and provide a feeling of well-being for the individual who has the potential for falling.
DIF: Cognitive Level: Comprehension REF: p. 322 OBJ: 5
TOP: Implementations for a Fall KEY: Nursing Process Step: Planning
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
, 4. A nurse explains that older adults account for a large percentage of the total deaths
resulting from falls. What is this percentage?
a. 13%
b. 27%
c. 40%
d. 72%
ANS: D
Older adults constitute only 12% to 13% of the total U.S. population, but they account for
72% of the total deaths resulting from falls.
DIF: Cognitive Level: Knowledge REF: p. 315 OBJ: 2
TOP: Incidence of Falls KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
5. A nurse is caring for an older adult patient who has undergone a total hip replacement.
What is the best action to reduce the risk of further injury?
a. Leave all the lights on in the room at night.
b. Leave the side rails down at all times to enable the patient to get to the bathroom quickly.
c. Keep the call bell and other frequently used items in easy reach.
d. Keep the bed in the high position to discourage the patient from getting out of bed without
assistance.
ANS: C
Keeping the call bell and other frequently used items within easy reach will prevent the
patient from having to reach, which increases the risk for falling.
DIF: Cognitive Level: Application REF: p. 318 | p. 321
OBJ: 5 TOP: Fall Prevention
KEY: Nursing Process Step: Planning
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
6. A nurse is talking to the family of a patient who has fallen several times. What should be
the most important intervention for preventing falls for the nurse to relay to this family?
a. Prevention
b. Hospitalization
c. Continuous observation
d. Restraint
ANS: A
The most important implementation for falls is prevention. The best prevention is education
that is aimed toward minimizing intrinsic and extrinsic factors.
DIF: Cognitive Level: Comprehension REF: p. 318 OBJ: 5
TOP: Fall Prevention KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Safety and Infection Control
7. How often should a nurse remove and release restraints when caring for a patient who
requires wrist restraints?
a. Once every 8 hours for at least 30 minutes
b. Once every 4 hours for at least 15 minutes
Chapter 20: Falls
Linton: Introduction to Medical-Surgical Nursing, 6th Edition
MULTIPLE CHOICE
1. What recommendation should a nurse make to the family of a patient diagnosed with
ataxia when preparing discharge to home?
a. Remove all scatter rugs from the home.
b. Rearrange the bedroom furniture.
c. Arrange for someone to stay with the patient 24 hours a day.
d. Purchase oversized shoes so that they are easy to get on.
ANS: A
Scatter rugs can slip and cause a patient to fall.
DIF: Cognitive Level: Application REF: p. 320 OBJ: 5
TOP: Fall Prevention KEY: Nursing Process Step: Planning
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
2. What should be the first intervention when a nurse finds that a patient has fallen?
a. Ask the patient to stand up.
b. Document the fall according to agency policy.
c. Remove or correct the cause of the fall.
d. Assess the circumstances of the fall and any injuries sustained.
ANS: D
The first implementation should be to assess what happened, determine whether any
injuries have occurred, and then document and correct the cause.
DIF: Cognitive Level: Application REF: p. 321-322 OBJ: 6
TOP: Implementations for a Fall KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
3. What should discharge planning for a patient who lives alone and is at high risk for falling
include?
a. Cannot go home unless someone is with him all the time
b. Must go to a long-term care facility
c. Can wear devices around the neck that can signal for help
d. Needs to be aware of the dangers of living alone
ANS: C
A person who is at risk for falling would be wise to have a call system to obtain help from
others. Devices worn around the neck that can send signals to a control center are effective
and provide a feeling of well-being for the individual who has the potential for falling.
DIF: Cognitive Level: Comprehension REF: p. 322 OBJ: 5
TOP: Implementations for a Fall KEY: Nursing Process Step: Planning
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
, 4. A nurse explains that older adults account for a large percentage of the total deaths
resulting from falls. What is this percentage?
a. 13%
b. 27%
c. 40%
d. 72%
ANS: D
Older adults constitute only 12% to 13% of the total U.S. population, but they account for
72% of the total deaths resulting from falls.
DIF: Cognitive Level: Knowledge REF: p. 315 OBJ: 2
TOP: Incidence of Falls KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
5. A nurse is caring for an older adult patient who has undergone a total hip replacement.
What is the best action to reduce the risk of further injury?
a. Leave all the lights on in the room at night.
b. Leave the side rails down at all times to enable the patient to get to the bathroom quickly.
c. Keep the call bell and other frequently used items in easy reach.
d. Keep the bed in the high position to discourage the patient from getting out of bed without
assistance.
ANS: C
Keeping the call bell and other frequently used items within easy reach will prevent the
patient from having to reach, which increases the risk for falling.
DIF: Cognitive Level: Application REF: p. 318 | p. 321
OBJ: 5 TOP: Fall Prevention
KEY: Nursing Process Step: Planning
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
6. A nurse is talking to the family of a patient who has fallen several times. What should be
the most important intervention for preventing falls for the nurse to relay to this family?
a. Prevention
b. Hospitalization
c. Continuous observation
d. Restraint
ANS: A
The most important implementation for falls is prevention. The best prevention is education
that is aimed toward minimizing intrinsic and extrinsic factors.
DIF: Cognitive Level: Comprehension REF: p. 318 OBJ: 5
TOP: Fall Prevention KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Safety and Infection Control
7. How often should a nurse remove and release restraints when caring for a patient who
requires wrist restraints?
a. Once every 8 hours for at least 30 minutes
b. Once every 4 hours for at least 15 minutes
