Deck 12: Safety

Question 1

The nurse identifies the older adult client at the greatest risk for a fall-related injury as the:

A)male with a history of a vitamin deficiency.
B)female with a diagnosis of osteoporosis.
C)male with a cognitive deficient.
D)female with a history of depression.

Answer 1

female with a diagnosis of osteoporosis.

Question 2

When assessing an older adult for intrinsic risk factors that increase the risk for falls, the nurse is particularly interested in which of the following? Select all that apply.

A)An unsteady gait when asked to walk without assistance
B)The inability to smoothly move from sitting to walking
C)The client's report that he wears corrective lenses
D)A history of osteoarthritis in left knee and ankle
E)Evidence of short-term memory deficient

Answer 2

An unsteady gait when asked to walk without assistance
The client's report that he wears corrective lenses
Evidence of short-term memory deficient

Question 3

When appropriately addressing safety issues, the geriatric nurse plans the client's care plan directed by the standard of care that requires:

A)promotion of both health and wellness by assuring safety.
B)minimizing the client's risk for physical injury while preserving autonomy.
C)identification of safety from injury as a client right.
D)emphasizing beneficence as a an ethical standard of nursing care.

Answer 3

minimizing the client's risk for physical injury while preserving autonomy.

Question 4

An older adult's risk for fall related injury is directly correlated to their ability to regain their balance.In order to evaluate this ability, the nurse assesses the client's:

A)inner ear for possible fluid buildup.
B)musculoskeletal hip, ankle, and shoulder strength.
C)large muscle strength in thighs and upper arms.
D)gait for steadiness.

Question 5

The geriatric nurse bases the decision to identify a specific client as a falls risk primarily on the:

A)presence of visual deficiencies and musculoskeletal weakness.
B)results determined by cognitive and physiological assessment tools.
C)degree of frailty and functional limitation observed.
D)inability to following instructions and communicate effectively.

Question 6

The geriatric nurse recognizes that the most effective intervention to minimize the potential of a fall injury for a 79-year-old client who is being discharged to home after hip replacement surgery is to:

A)identify the most common causes of falls that the client is likely to encounter.
B)discuss what kind of in-home assistance the client will need.
C)impress the client with the importance of being careful not to fall.
D)educate the client that falling is not a normal part of aging.

Question 7

A cognitively impaired older adult client is a resident at a skilled nursing facility.Because no family is available to voice choices regarding the client's care, the nurse acting as the client's advocate will consistently address the client's risk for injury issues based on:

A)preferences generally expressed by cognitive clients.
B)professional nursing knowledge.
C)implementation of the less restrictive intervention.
D)established facility policies and procedures.

Question 8

An older adult has been diagnosed with presbyopia.In order to help minimize the client's risk for falls, the nurse suggests:

A)that the edges of steps be painted a contrasting color.
B)using sunglasses when driving.
C)wearing a wide-brimmed hat when spending time outdoors.
D)hanging blinds over sunny windows.

Question 9

A 73-year-old client is diagnosed with bilateral osteoarthritis of the knees.To best address the long-term risk for falls, the nurse encourages the client to:

A)use assistive mobility devises when necessary.
B)report exacerbation of symptoms to her health care provider promptly.
C)add a daily walk to her routine to exercise her knees appropriately.
D)take analgesic medication as prescribed to manage joint pain.

Question 10

Which nursing intervention best demonstrates the understanding that older adults are at increased risk for falls because of normal age-related changes?

A)Speaking in a loud voice when warning the client about safety hazards
B)Turning on bright lights in the room so the client can see objects such as furniture
C)Encouraging the client to rise from a supine position slowly
D)Advising the client to avoid exercising painful joints

Question 11

An older adult has been diagnosed with a sinus infection.In order to best minimize the client's risk for a fall-related injury, the nurse teaches her:

A)that there is a possibility of prodromal falls.
B)to take her antibiotic medication with food.
C)to recognize the early symptoms of fluid buildup in the middle ear.
D)about the increased risks of falls related to normal aging.

Question 12

An older client diagnosed with dementia has begun behaviors that put her at risk for falling.The client's son tells the nurse that "physical restraints may be used to keep her safe." The nurse responds that:

A)"I'll document that so that the staff can use them when necessary."
B)"Physical restraints are seldom effective on clients with dementia."
C)"The staff will resort to the use of physical restraints only as a last resort."
D)"There are more effective methods to use to help ensure her safety."