Deck 12: Maintaining Mobility and Environmental Safety

Question 1

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?

A) Tell the older adult to use an assistive device until her balance and strength improve.
B) Implement a multifactorial fall prevention intervention to prevent future falls.
C) Help the older adult to learn how to exercise the core group of muscles.
D) Instruct the older adult to enroll in an exercise program for eight weeks.

Answer 1

Implement a multifactorial fall prevention intervention to prevent future falls.

Question 2

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

A) Stride
B) Speed
C) Balance
D) Flexibility

Answer 2

Balance

Question 3

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

A) Use of restraints on older patients helps prevent injuries from falls.
B) Falls that do not cause physical injury are not significant.
C) The Braden Scale provides a measure of a patient's energy and initiative.
D) Lowering the bed and using night lights are interventions to increase patient safety.

Answer 3

Lowering the bed and using night lights are interventions to increase patient safety.

Question 4

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?

A) Information about the environment in hospital and at home
B) The patient's emotional status
C) The patient's financial status
D) The patient's occupational history

Question 5

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

A) When using a walker, armless chairs provide more ease when moving from sitting to standing.
B) Assistive devices do not contribute to falls and injuries.
C) Older adults save money by adapting assistive devices given to them from their friends.
D) A walker is most useful for unilateral disabilities, but not for bilateral problems.

Question 6

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?

A) A brightly lit, blue room with cozy throw rugs.
B) A room with orange carpeting and soft lighting.
C) A brightly lit, blue room with waxed vinyl floors.
D) A room for television and crafts.

Question 7

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?

A) Call for someone to bring the sign.
B) Show him how to use the call bell.
C) Provide a urinal and drinking water.
D) Instruct the patient to call for help.

Question 8

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?

A) Inform staff about his risk for falls.
B) Place a concave mattress on the bed.
C) Provide frequent walks in the hallway.
D) Help him learn to use an assistive device.

Question 9

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?

A) It is not fair for older adults to have to deal with an uncomfortable environment.
B) Some of the residents are wearing blankets around their shoulders to keep warm.
C) An ambient temperature of 17°C (62° F) is unsuitable for older people because they have impaired thermoregulation.
D) It feels much warmer in the administration wing than out in the patient care areas.

Question 10

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?

A) The patient holds the front of the walker.
B) The patient has a walker with four wheels.
C) The patient takes four steps into the walker.
D) The patient takes the walker to the elevator.

Question 11

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?

A) Apply bilateral upper extremity restraints.
B) Administer haloperidol (Haldol) for agitation.
C) Close the door to her room to reduce the noise.
D) Use a temporary air splint to prevent elbow and wrist flexion.

Question 12

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?

A) Complaints of shivering
B) Temperature of the household
C) Types of food preparation
D) Patient indicators of injury