Test Bank for Toward Healthy Aging,
11th Edition Chapter 20: Falls and Fall
Risk Reduction 11th Edition by Theris A.
Touhy
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 - ANSANS: 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.
2. An 88-year-old admitted to the hospital with a diagnosis of pneumonia 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 patient develops a care plan that includes the
diagnosis Risk for Falls. Which would be a priority nursing intervention for this client?
a. Performing a fall assessment.
b. Keeping all of the side rails up on the client's bed at nighttime.
c. Placing the client on bed rest to minimizing falling.
d. Assessing the client's dietary intake for calcium adequacy. - ANSANS: 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.
3. A nurse is assessing an older adult's risk for falls. One of the questions asked is whether the
older adult has fallen in the past year. What is the reason behind asking this question?
a. The risk of falling again is greater for persons who have fallen in the past year.
b. They are more likely to sustain injuries if they fall again than persons who did not fall in the
past year.
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