chapter 20 - Chapter 20: Falls MULTIPLE CHOICE 1. The nurse...

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Chapter 20: Falls MULTIPLE CHOICE 1. The nurse caring for a patient with ataxia would recommend that the family, in preparation for discharge home: 1. remove all scatter rugs from the home. 2. rearrange the bedroom furniture. 3. arrange for someone to stay with the patient 24 hours a day. 4. purchase oversized shoes so that they are easy to get on. ANS: 1 Scatter rugs can slip and cause a patient to fall. 2. When the nurse finds that a patient has fallen, the first intervention should be to: 1. have the patient to stand up. 2. document the fall according to agency policy. 3. remove or correct the cause of the fall. 4. assess the circumstances of the fall and any injuries sustained. ANS: 4 The first implementation should be to assess what happened and whether there are any injur- ies, and then document and correct the cause. 3. Discharge planning for a patient who lives alone and is at high risk for falling should in- clude telling the patient: 1. that he cannot go home unless someone is with him all the time. 2. that he must go to a long-term care facility. 3. about devices worn around the neck that can signal for help. 4. about the dangers of living alone. ANS: 3 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 very ef- fective and provide a feeling of well-being for the potential faller.
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4. The nurse explains that the older adults account for a large percentage of the total deaths resulting from falls. This percentage is: 1. 13%. 2. 27%. 3. 40%. 4. 72%. ANS: 4 Older adults constitute only 12% to 13% of the total U.S. population, but they account for 72% of total deaths resulting from falls. 5. The nurse is caring for an older adult patient who has undergone a total hip replacement. To reduce the risk of further injury, the nurse would: 1. leave all the lights in the room on at night. 2. leave the side rails down at all times so that the patient can get to the bathroom quickly. 3. keep the call bell and other frequently used items in easy reach. 4. keep the bed in the high position so that the patient will not be tempted to get out of bed alone. ANS: 3 Keeping the call bell and other frequently used items within easy reach will prevent the pa- tient from having to reach, which increases the risk for falling. 6. The nurse is talking to the family of a patient who has fallen several times. She knows that her teaching should be aimed toward the most important intervention for falls, which is: 1. prevention. 2. hospitalization. 3. continuous observation. 4. restraint. ANS: 1 The most important implementation for falls is prevention. The best prevention is education and is aimed toward minimizing intrinsic and extrinsic factors.
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7. When caring for a patient who requires wrist restraints, the nurse should be sure to remove and release the restraints once every: 1. 8 hours for at least 30 minutes. 2.
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This note was uploaded on 10/14/2010 for the course HNSC HNSC 6.1 taught by Professor Katz during the Spring '10 term at CUNY Brooklyn.

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chapter 20 - Chapter 20: Falls MULTIPLE CHOICE 1. The nurse...

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