Prevention
What should always be placed within the patient's reach?
Call Light
When transferring a patient what is the name of the person who leads each transfer?
Head / Lead
This safety device, which has four wheels, is often used for people that are unable to ambulate.
Wheelchair
Which common household items increase fall risk if left on the floor?
Rugs, cords, clutter
Falls are the leading cause of injury and injury related death among which age group?
Adults 65+
Restraints decrease fall risk True/False?
False
Before transferring a patient from bed to wheelchair, the nurse should perform this essential step to prevent falls and ensure safety.
Lock both the bed and wheelchair wheels.
This frame-like device has four legs and is used to provide stability and support to a user when standing or moving.
Walker
Which factor is considered extrinsic rather than intrinsic?
A) Muscle weakness
B) Poor vision
C) Lack of stair handrails
D) Gait and balance problems
c. Lack of stair handrails
More than what fraction of older adults fall each year in the United States?
1 in 4
What are the three main categories of falls?
Accidental fall, Anticipated physiologic fall, unanticipated physiologic fall
When transferring a patient with weakness on one side, the nurse should stand on which side?
weak side
The nurse is teaching a patient how to use a cane. Which action shows correct understanding?
A) Moves cane and weak leg forward together
B) Moves cane and strong leg forward together
C) Holds cane on weak side for support
D) Uses cane only on stairs
A) Moves cane and weak leg forward together
Which client is at the greatest risk for falls?
A. A 28-year-old with a leg cast
B. A 72-year-old taking a diuretic and sedative
C. A 45-year-old recovering from pneumonia
D. A 65-year-old using a hearing aid
B. A 72 year old taking a diuretic and sedative
The My Mobility Plan, created by the CDC, outlines which 3 categories?
myself, myhome, mycommunity
An older adult reports 2 previous falls within the past year, but denies injuries. The nurse recognizes that this information is:
a. a major predictor in future falls and possible injury
b. likely unrelated to current fall risk
c.not significant since the falls did not cause injury
d. only relevant if the patient uses assistive devices
a. a major predictor in future falls and possible injury
A fall risk patient has orthostatic hypotension. How can the nurse move the patient safely?
move the patient slowly, allow them to dangle, assess for dizziness before and after standing fully
During a home safety assessment, the nurse notes that the client has a high risk for falls. Which intervention should the nurse recommend to specifically address the client’s risk of falling in the bathroom?
a. Using a rubber bath mat on the tub floor
b. Installing a grab bar next to the toilet and in the shower
c. Placing a commode chair next to the bed
d. Raising the toilet seat height
b. Installing a grab bar next to the toilet and in the shower
A nurse notes that a client taking a sedative medication exhibits postural hypotension and slow reflexes. Which two fall risk categories apply here?
Intrinsic,Modifiable
Which CDC initiative supports healthcare providers in making fall prevention a routine part of their practice?
STEADI initiative
A 78-year-old client is taking a diuretic and antihypertensive medication. Which intervention should the nurse implement to prevent falls?
A. Encourage the client to ambulate right after taking medications
B. Keep the lights dim to promote rest
C. Instruct the client to change positions slowly
D. Place a commode far from the bed to promote walking
c. Instruct the client to change positions slowly
You are assisting a 69-year-old patient with a history of falls up a flight of stairs using a walker. The patient has mild right leg weakness. Which action by the nurse demonstrates correct and safe technique?
A) Stand in front of the patient, holding their hands for balance as they step up with the affected leg first.
B) Stand slightly behind and to the side using a gait belt, as the patient steps up first with the unaffected leg, then brings the walker and affected leg up.
C) Allow the patient to pull themselves up using the walker while you stabilize it from the bottom of the stairs.
D) Position yourself directly behind the patient with hands under their arms for support as they step up.
B) Stand slightly behind and to the side using a gait belt, as the patient steps up first with the unaffected leg, then brings the walker and affected leg up.
The nurse assesses a client’s cane height. Which finding indicates correct adjustment?
A. The top of the cane is at the client’s hip level.
B. The client’s elbow is flexed about 15–30 degrees.
C. The cane reaches the client’s shoulder level.
D. The client’s arm is completely straight when holding the cane.
B. The client’s elbow is flexed about 15–30 degrees.
Which two evaluation models are used to identify a patient's risk for falling?
Hendrich II Fall Risk Model and the Morse Fall Scale
Older adult falls result in about $80 billion in medical costs every year, how much of this does medicare shoulder?
2/3