Fall Risk Assessment And Prevention

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Quizzes Created: 26 | Total Attempts: 55,056
Questions: 20 | Attempts: 1,061

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Assessment Quizzes & Trivia

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Questions and Answers
  • 1. 

    An 87-year-old woman comes into your MSK clinic with a complaint of R shoulder pain. She says that she fell 3 days ago at home while walking out of her bathroom. She landed on her R shoulder and denies hitting her head. She has a past medical history of type 2 diabetes with peripheral neuropathy, hypertension, and osteoarthritis. She takes glipizide for her diabetes, lisinopril for her hypertension, amitriptyline for neuropathy, and acetaminophen as needed for joint pain. On exam, her postural vital signs are unremarkable. An evaluation of her gait shows her to have some mild swaying on ambulation only. 

  • 2. 

    What are some of the interventions you may include in a patient’s individualized care plan?

    • A.

      Frequent/Hourly Rounding to assess needs of the patient

    • B.

      Communicate high risk to other care givers when handing-off

    • C.

      Engage the patient and family in education regarding the risk of falls and how to prevent falls

    • D.

      All of the above

    Correct Answer
    D. All of the above
    Explanation
    The correct answer is "All of the above" because all three interventions mentioned - frequent/hourly rounding, communicating high risk to other caregivers, and engaging the patient and family in fall prevention education - are important components of an individualized care plan for a patient. Frequent rounding helps assess the patient's needs regularly, communicating high risk to other caregivers ensures continuity of care, and educating the patient and family about fall prevention promotes patient safety. Therefore, including all of these interventions in the care plan would be beneficial for the patient.

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  • 3. 

    Staying “within arm’s reach” of a patient at risk for falls while toileting is defined as beingright outside the room to give the patient privacy.

    • A.

      True

    • B.

      False

    Correct Answer
    B. False
    Explanation
    False. Outside of the room does not meet the definition. Staying Within Arm’s Reach is a policy
    which requires a caregiver to be immediately available and within reach for patients at risk for
    falling.

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  • 4. 

    What are some of the interventions shown to assist with preventing falls? (Select all thatapply)

    • A.

      Shift or Safety Huddles to review high risk patients

    • B.

      Patient Communication Boards

    • C.

      Environmental Rounds

    • D.

      Completing a falls risk assessment

    Correct Answer(s)
    A. Shift or Safety Huddles to review high risk patients
    B. Patient Communication Boards
    C. Environmental Rounds
    D. Completing a falls risk assessment
    Explanation
    All answers are considered appropriate interventions for prevention of falls.

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  • 5. 

    Medications that a patient is administered play a very small role in whether a patient is at riskfor falls.

    • A.

      True

    • B.

      False

    Correct Answer
    B. False
    Explanation
    False. Medications can play a very large role in the patient’s risk for falls.

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  • 6. 

    Falls with injury can cause lasting pain, limit activities of daily living, and increase thelikelihood of skilled nursing placement.

    • A.

      True

    • B.

      False

    Correct Answer
    A. True
    Explanation
    True. False can have several long-lasting negative outcomes for a patient.

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  • 7. 

    Which of these would be a good first step to decrease her risk of repeat falls?

    • A.

      Recommend she purchase hip protectors.

    • B.

      Start an exercise program directed by your physical therapist.

    • C.

      Lower her dose of glipizide.

    • D.

      Change amitriptyline to another drug for neuropathy.

    Correct Answer
    D. Change amitriptyline to another drug for neuropathy.
    Explanation
    (d) Amitriptyline is a drug with significant anticholinergic side effects that could be
    associated with increased confusion and falls in the elderly. Discontinuing it would be a
    quick and potentially effective intervention to decrease fall risk. Hip protectors might reduce
    the impact of a fall, but not the probability itself. An evaluation of gait revealed some balance
    issues, but not problems with proximal strength, so (b) would be insufficient without first
    removing a potentially exacerbating medication. There is no evidence of hypoglycemia, so
    (c) is not the right answer.

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  • 8. 

    Which of the following is true regarding falls in the elderly?

    • A.

      A patient should not use a walker to ambulate if their motor strength is intact.

    • B.

      Hip fractures are not the most frequent type of fall-related fractures.

    • C.

      A motorized scooter is a better option to prevent falls in the elderly.

    • D.

      Medication use may contribute to increased fall risk.

    Correct Answer
    D. Medication use may contribute to increased fall risk.
    Explanation
    (d) Medication use in the elderly, for example use of medications with prominent anticholinergic side-effect profiles, can put a patient at increased risk of falls. It is not correct
    to assume that a properly selected assistive device puts an elderly patient at risk of falls; on
    the contrary, it may help stabilize their gait pattern. Hip fractures are the most common fall related
    fracture. Motorized scooters are not a practical or effective solution to the problem of
    falls in the elderly.

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  • 9. 

    Patients who fall, even if they are uninjured, are at risk of another fall.

    • A.

      True

    • B.

      False

    Correct Answer
    A. True
    Explanation
    (a) True. According to Vellas et al (1997), many people who fall, even those who are not
    injured, develop a fear of falling. This fear may cause them to limit their activities, leading to
    reduced mobility and physical fitness, and increasing their actual risk of falling.

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  • 10. 

    One way to standardize an approach to fall risk identification is through the use of a falls riskscreening tool or assessment.

    • A.

      True

    • B.

      False

    Correct Answer
    A. True
    Explanation
    True. Standardization reduces the likelihood of variability and omitting important information.

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  • 11. 

    What patients are at the highest risk for falling? (Select all that apply)

    • A.

      History of falls

    • B.

      Impaired cognition

    • C.

      Impaired mobility

    • D.

      Patient in a cluttered room

    Correct Answer(s)
    A. History of falls
    B. Impaired cognition
    C. Impaired mobility
    D. Patient in a cluttered room
    Explanation
    Patients who have a history of falls are at a higher risk of falling again in the future. This could be due to underlying health conditions or physical impairments that increase their vulnerability to falls. Impaired cognition, such as dementia or confusion, can also contribute to a higher risk of falling as it affects their ability to navigate their surroundings safely. Impaired mobility, such as weakness or difficulty walking, can make it more challenging for patients to maintain their balance and prevent falls. Additionally, being in a cluttered room can increase the risk of tripping or stumbling, further increasing the likelihood of a fall.

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  • 12. 

    Which of the following is true regarding falls in the elderly?

    • A.

      A patient should not use a walker to ambulate if their motor strength is intact.

    • B.

      Hip fractures are not the most frequent type of fall-related fractures.

    • C.

      A motorized scooter is a better option to prevent falls in the elderly.

    • D.

      Medication use may contribute to increased fall risk.

    Correct Answer
    D. Medication use may contribute to increased fall risk.
    Explanation
    Medication use may contribute to increased fall risk.

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  • 13. 

    What are the most common risk factors for a fall?

    • A.

      Inappropriate footwear

    • B.

      Weak muscles & poor balance

    • C.

      Consuming too much alcohol

    • D.

      All of the above

    Correct Answer
    D. All of the above
    Explanation
    The most common risk factors for a fall include wearing inappropriate footwear, having weak muscles and poor balance, and consuming excessive amounts of alcohol. Wearing shoes that are not suitable for the activity or do not provide enough support can increase the risk of falling. Weak muscles and poor balance make it harder to maintain stability and can lead to falls. Alcohol consumption can impair coordination and judgment, making falls more likely. Therefore, all of these factors contribute to the risk of falling.

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  • 14. 

    A fall in people with osteoporosis can result in fractures. What can help prevent osteoporosis?

    • A.

      Regular exercise & increased calcium and vitamin D intake

    • B.

      Sedentary lifestyle - why take the risk

    • C.

      It runs in the family. It’s impossible.

    • D.

      Increase fluid intake

    Correct Answer
    A. Regular exercise & increased calcium and vitamin D intake
    Explanation
    Regular exercise and increased calcium and vitamin D intake can help prevent osteoporosis. Exercise helps to strengthen bones and increase bone density, reducing the risk of fractures. Calcium and vitamin D are essential for bone health, as they promote the absorption and utilization of calcium in the body. Adequate intake of these nutrients can help maintain strong and healthy bones, reducing the risk of osteoporosis.

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  • 15. 

    Fear of falling can lower your quality of life and stop you from:

    • A.

      Doing the activities you enjoy

    • B.

      Visiting friends and family

    • C.

      Leading an active life

    • D.

      All of the above

    Correct Answer
    D. All of the above
    Explanation
    The fear of falling can significantly impact one's quality of life by limiting their ability to engage in activities they enjoy, such as hobbies or sports. It can also prevent them from visiting friends and family, as they may be afraid of navigating unfamiliar environments or stairs. Additionally, the fear of falling can discourage individuals from leading an active life, as they may avoid physical activities out of fear of injury. Therefore, all of the given options are valid consequences of the fear of falling.

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  • 16. 

    The nurse is planning care with an older adult who is at risk for falling because of postural hypotension. Which of the following will be most effective in preventing falls in this client?

    • A.

      Complete a fall diary.

    • B.

      Attach a sensor to the client that will alarm when client attempts to get up.

    • C.

      Encourage a family member to stay with the client.

    • D.

      Instruct the client to sit, obtain balance, dangle legs, and rise slowly.

    Correct Answer
    D. Instruct the client to sit, obtain balance, dangle legs, and rise slowly.
    Explanation
    Answer: d
    There are many risk factors for falls in older adults. Postural hypotension is a common risk. The nurse should instruct the client about postural hypotension and provide practical information regarding how to sit on the bed or chair, dangle the legs first and then rise slowly, supported by a walker if necessary. A diary of instances of an individual’s falls may predict future falls by tracking the events and behaviors at the time of the fall, but is not the most effective in preventing the fall. Attaching a sensor to the client or bed is reserved for clients who are at a serious risk for injury.

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  • 17. 

    What are the most serious consequences of a fall?

    • A.

      Hip fractures

    • B.

      Head injuries

    • C.

      Pressure sores

    • D.

      Muscle rigidity

    Correct Answer
    A. Hip fractures
    Explanation
    Hip fractures are one of the most serious consequences of a fall. When a person falls, the impact on the hip can cause the bone to break or fracture. Hip fractures can be extremely painful and can lead to limited mobility, loss of independence, and a decreased quality of life. In older adults, hip fractures can also increase the risk of complications such as pneumonia, blood clots, and pressure sores. Prompt medical attention and appropriate treatment are crucial to prevent further complications and promote healing.

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  • 18. 

    Wearing the right footwear is important. What is the ideal footwear?

    • A.

      Firm back and cover with adjustable fastening, ankle support and non-slip sole

    • B.

      Soft leather sole which is flexible

    • C.

      Soft, cushioned material with a tight fit

    • D.

      Loose footwear

    • E.

      Shoes with high or block heels

    Correct Answer
    A. Firm back and cover with adjustable fastening, ankle support and non-slip sole
    Explanation
    The ideal footwear should have a firm back and cover to provide stability and support to the foot. It should also have an adjustable fastening to ensure a secure fit. Ankle support is important to prevent injuries and promote proper alignment. Lastly, a non-slip sole is essential to provide traction and prevent slips and falls.

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  • 19. 

    What do you would advise if your feel dizzy when he/she standing up in the morning?

    • A.

      Stay in bed. There is no need to get up.

    • B.

      Sit up in the bed for a few minutes before standing up. Stand up for a minute before walking.

    • C.

      Get up quickly and walk around until you feel better.

    • D.

      Its common, do nothing about it.

    Correct Answer
    B. Sit up in the bed for a few minutes before standing up. Stand up for a minute before walking.
    Explanation
    The correct answer advises the person to sit up in bed for a few minutes before standing up and then stand up for a minute before walking. This is a recommended approach to prevent dizziness when transitioning from lying down to standing up. By gradually transitioning from a lying position to a sitting position and then to a standing position, it allows the body to adjust to the change in posture and helps to maintain blood pressure, reducing the likelihood of dizziness.

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  • 20. 

    Which of the following can help prevent falls in the elderly?

    • A.

      Get GP to review medication

    • B.

      Remove clutter from indoors and outdoors

    • C.

      Install lights in dark hallways and stairways

    • D.

      Keep feet healthy

    • E.

      Wear appropriate footwear

    • F.

      Eat a balanced diet

    • G.

      Exercise regularly

    • H.

      All of the above

    Correct Answer
    H. All of the above
    Explanation
    All of the options listed can help prevent falls in the elderly. Getting the GP to review medication ensures that any side effects or interactions that may increase the risk of falls are identified and addressed. Removing clutter from indoors and outdoors reduces the chances of tripping and falling. Installing lights in dark hallways and stairways improves visibility and reduces the risk of missteps. Keeping feet healthy and wearing appropriate footwear provide stability and reduce the risk of slipping. Eating a balanced diet and exercising regularly improve overall strength and balance, further reducing the risk of falls.

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  • 21. 

    You only need to do a fall risk assessment once on your patient because they likely will notchange status during their stay.

    • A.

      True

    • B.

      False

    Correct Answer
    B. False
    Explanation
    False. Patients often change their physiological and mental status during a hospital stay.
    Reassessment is imperative to identify fall risk status changes.

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