Exam 12: Maintaining Mobility and Environmental Safety

The nurse determines that an older adult who has chronic bronchitis is at high risk for falls, but he repeatedly tries to ambulate without assistance. Which alternative measure to restraints is contraindicated for this older adult?

An older male adult was oriented and responded correctly in the hospital, but he is disoriented and confused in his home after discharge. Which is the first issue the home nurse should examine to determine if an environmental issue is contributing to the patient's condition at home?

An older female adult who receives intravenous (IV) fluids is making wide gesticulations with her arms and insulting the nursing staff loudly. Which intervention should the nurse implement to maintain safe, effective nursing care initially?

After assessing an older male adult in his bed, the nurse determines that he is at high risk for falls. The nurse leaves the room to get a fall risk sign and returns to find him on the floor pleading for help. What is the most important intervention the nurse should have implemented to prevent this event?

The nurse is discharging an older female adult who is using a walker from rehabilitative care. Which observation does the nurse use to determine that this patient is prepared for discharge?

The nurse assesses the quality of which patient characteristic when applying the Get Up and Go test from the Hendrich II Fall Risk Model?

Which of the following statements is true about mobility and safety for older adults?

The nurse can place an older adult into one of four patient rooms. Which one of the following is a suitable room for an older adult?

The nurse is assessing an older adult in order to plan for fall screening prevention. What information should the nurse gather for the plan of care?

The overall temperature in your gerontological unit is 17°C (62°F) during the evening shift. In documenting this concern to administration, which factor is the most important for the health and well-being of older adults?

The nurse wants to encourage an older female adult who lost her balance and fell to include daily exercise as a means of improving her balance and strength. What recommendation and intervention according to the RNAO Best Practice Guideline (BPG): Prevention of Falls and Fall Injuries in the Older Adult is appropriate for the older adult?

Which statement is true about assistive devices to aid older adults with impaired mobility?