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
... [Show More] 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. 186 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. 188 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. 188 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 t [Show Less]