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Introduction to Medical Surgical Nursing, 5th Edition Linton Test Bank

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Introduction to Medical Surgical Nursing, 5th Edition Linton Test Bank

ISBN-13: 978-1437717082

ISBN-10: 143771708X

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Introduction to Medical Surgical Nursing, 5th Edition Linton Test Bank

ISBN-13: 978-1437717082

ISBN-10: 143771708X

 

 

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Free Nursing Test Questions:

 

Linton: Introduction to Medical-Surgical Nursing, 5th Edition

 

Chapter 20: Falls

 

Test Bank

 

MULTIPLE CHOICE

 

  1. In preparation for discharge home, the nurse caring for a patient with ataxia would recommend that the family:
a. Remove all scatter rugs from the home.
b. Rearrange the bedroom furniture.
c. Arrange for someone to stay with the patient 24 hours a day.
d. Purchase oversized shoes so that they are easy to get on.

 

ANS: A

Scatter rugs can slip and cause a patient to fall.

 

DIF:   Cognitive Level: Application        REF:  p. 329            OBJ:  5

TOP:  Fall Prevention                              KEY: Nursing Process Step: Planning

MSC: “NCLEX: Safe, Effective Care Environment: Safety and infection control”

 

  1. When the nurse finds that a patient has fallen, the first intervention should be to:
a. Ask the patient to stand up.
b. Document the fall according to agency policy.
c. Remove or correct the cause of the fall.
d. Assess the circumstances of the fall and any injuries sustained.

 

ANS: D

The first implementation should be to assess what happened, determine whether any injuries have occurred, and then document and correct the cause.

 

DIF:   Cognitive Level: Application        REF:  p. 330            OBJ:  6

TOP:  Implementations for a Fall            KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic care and comfort

 

  1. Discharge planning for a patient who lives alone and is at high risk for falling should include telling the patient that he:
a. Cannot go home unless someone is with him all the time.
b. Must go to a long-term care facility.
c. Can wear devices around the neck that can signal for help.
d. Needs to be aware of the dangers of living alone.

 

ANS: C

A person who is at risk for falling would be wise to have a call system to obtain help from others. Devices worn around the neck that can send signals to a control center are effective and provide a feeling of well-being for the individual who has the potential for falling.

 

DIF:   Cognitive Level: Application        REF:  p. 330            OBJ:  6

TOP:  Implementations for a Fall            KEY: Nursing Process Step: Planning

MSC: “NCLEX: Safe, Effective Care Environment: Safety and infection control”

 

  1. The nurse explains that the older adults account for a large percentage of the total deaths resulting from falls. This percentage is:
a. 13%
b. 27%
c. 40%
d. 72%

 

ANS: D

Older adults constitute only 12% to 13% of the total U.S. population, but they account for 72% of the total deaths resulting from falls.

 

DIF:   Cognitive Level: Knowledge        REF:  p. 323            OBJ:  2

TOP:  Incidence of Falls                          KEY: Nursing Process Step: Implementation

MSC: “NCLEX: Safe, Effective Care Environment: Safety and infection control”

 

  1. The nurse is caring for an older adult patient who has undergone a total hip replacement. To reduce the risk of further injury, the nurse would:
a. Leave all the lights on in the room at night.
b. Leave the side rails down at all times to enable the patient to get to the bathroom quickly.
c. Keep the call bell and other frequently used items in easy reach.
d. Keep the bed in the high position to discourage the patient from getting out of bed without assistance.

 

ANS: C

Keeping the call bell and other frequently used items within easy reach will prevent the patient from having to reach, which increases the risk for falling.

 

DIF:   Cognitive Level: Application        REF:  p. 326            OBJ:  5

TOP:  Fall Prevention                              KEY: Nursing Process Step: Planning

MSC: “NCLEX: Safe, Effective Care Environment: Safety and infection control”

 

  1. The nurse is talking to the family of a patient who has fallen several times. She knows that her teaching should be aimed toward the most important intervention for falls, which is:
a. Prevention
b. Hospitalization
c. Continuous observation
d. Restraint

 

ANS: A

The most important implementation for falls is prevention. The best prevention is education that is aimed toward minimizing intrinsic and extrinsic factors.

 

DIF:   Cognitive Level: Comprehension  REF:  p. 326            OBJ:  5

TOP:  Fall Prevention                              KEY: Nursing Process Step: Planning

MSC: NCLEX: Health Promotion and Maintenance: Safety and infection control

 

  1. When caring for a patient who requires wrist restraints, the nurse should remove and release the restraints once every:
a. 8 hours for at least 30 minutes
b. 4 hours for at least 15 minutes
c. 2 hours for at least 10 minutes
d. 1 hour for at least 5 minutes

 

ANS: C

Physical restraints must be removed and released every 2 hours for 10 minutes. In addition, they should be frequently checked to ensure that the restraint is properly used and is providing adequate protection and comfort without impeding circulation or breathing.

 

DIF:   Cognitive Level: Application        REF:  p. 326            OBJ:  4

TOP:  Physical Restraints                        KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic care and comfort

 

  1. The older adult patient in a long-term care facility is at risk for injury because of confusion. The patient’s gait is stable. To prevent injury to the patient, the best method of restraint if prescribed would be a(n):
a. Geriatric chair
b. Ambularm bracelet
c. Vest restraint
d. Wrist or ankle restraint or both

 

ANS: B

If a physical restraint is used, the least restrictive device is best. This patient has a stable gaitRemember, the alarm bracelet allows the patient to move about freely while preventing him from leaving the premises.

 

DIF:   Cognitive Level: Application        REF:  p. 328            OBJ:  4

TOP:  Physical Restraints                        KEY: Nursing Process Step: Planning

MSC: “NCLEX: Safe, Effective Care Environment: Safety and infection control”

 

  1. The nurse is admitting a new patient to the nursing unit. When conducting the admission procedure, assessing the patient’s risk for falling is important by asking:
a. “How many times have you fallen before?”
b. “How many hours do you sleep at night?”
c. “What are your eating habits?”
d. “Do you smoke?”

 

ANS: A

People who are at the greatest risk for falls and injury are those who have fallen before.

 

DIF:   Cognitive Level: Analysis             REF:  p. 326            OBJ:  5

TOP:  Fall Prevention                              KEY: Nursing Process Step: Assessment

MSC: “NCLEX: Safe, Effective Care Environment: Safety and infection control”

 

  1. The patient has asked the nurse to assist him to ambulate to the bathroom. The nurse is aware that the patient is currently taking an antidepressant medicationRemember, she should:
a. Never leave the patient alone in his room.
b. Ask the patient if he could use the bedside commode instead of going to the bathroom.
c. Make suicidal precautions as part of the care plan.
d. Ask the patient to sit on the side of the bed for a minute or two before standing, and then stand slowly.

 

ANS: D

Psychotropic drugs, such as antidepressants, commonly cause orthostatic hypotension. The patient should sit on the side of the bed and then stand slowly to prevent falling.

 

DIF:   Cognitive Level: Analysis             REF:  p. 326            OBJ:  3

TOP:  Chemical Restraints                       KEY: Nursing Process Step: Implementation

MSC: “NCLEX: Safe, Effective Care Environment: Safety and infection control”

 

  1. In reviewing a patient’s medication administration record, the nurse is aware that some medications are considered to be chemical restraints. Of the following medications, the nurse recognizes the chemical restraint to be:
a. Warfarin (Coumadin)
b. Alprazolam (Xanax)
c. Isosorbide (Isordil)
d. Ibuprofen (Motrin)

 

ANS: B

Alprazolam (Xanax) is a psychotropic drug used as a chemical restraint.

 

DIF:   Cognitive Level: Knowledge        REF:  p. 324            OBJ:  4

TOP:  Chemical Restraints                       KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: Pharmacological therapies

 

  1. The nurse in a long-term care facility determines the need to place a vest restraint on a patient. The patient does not want the vest restraint applied. The nurse should:
a. Apply the restraint anyway.
b. Call the physician, and obtain an order for the restraint.
c. Medicate the patient with a sedative, and then apply the restraint.
d. Compromise with the patient and use wrist restraints.

 

ANS: B

A physician’s order is required for restraint use, and the order must specify the duration and circumstances under which the restraint may be used.

 

DIF:   Cognitive Level: Application        REF:  p. 324            OBJ:  4

TOP:  Physical Restraints                        KEY: Nursing Process Step: Implementation

MSC: “NCLEX: Safe, Effective Care Environment: Safety and infection control”

 

  1. After a patient has fallen, the most appropriate nursing intervention is to:
a. Apply a vest restraint.
b. Have the patient begin ambulating as soon as possible.
c. Administer haloperidol (Haldol) as prescribed or as needed (PRN).
d. Apply wrist restraints.

 

ANS: B

The patient should begin ambulating as soon after a fall as possible to prevent the hazards of bedrest and to restore confidence. Applying restraints after a fall is tempting, but avoiding their use, if possible, is best.

 

DIF:   Cognitive Level: Application        REF:  p. 330            OBJ:  6

TOP:  Implementations for a Fall            KEY: Nursing Process Step: Planning

MSC: NCLEX: Psychosocial Integrity: Coping and adaptation

 

  1. The nurse clarifies that the best definition of a fall is a circumstance in which the patient unexpectedly:
a. Falls to the ground, floor, or lower level
b. Loses consciousness, resulting in injury
c. Loses balance, resulting from a lack of equilibrium
d. Injures self, resulting from a side effect of a medication

 

ANS: A

Definitions of falls vary, but a fall is an unintentional event that is unrelated to medication or loss of consciousness and that results in injury.

 

DIF:   Cognitive Level: Knowledge        REF:  p. 323            OBJ:  1

TOP:  Falls               KEY: Nursing Process Step: Implementation

MSC: “NCLEX: Safe, Effective Care Environment: Safety and infection control”

 

  1. In assessing the potential risk factors a patient may have for falling, the nurse should keep in mind that the two major factors that cause falls are:
a. Mental and emotional factors
b. Aging and physical factors
c. Genetic and environmental factors
d. Intrinsic and extrinsic factors

 

ANS: D

Intrinsic factors are related to the functioning of the individual (e.g., aging process, physical illness). Extrinsic factors are related to the environment.

 

DIF:   Cognitive Level: Knowledge        REF:  p. 323            OBJ:  2

TOP:  Incidence of Falls                          KEY: Nursing Process Step: Assessment

MSC: “NCLEX: Safe, Effective Care Environment: Safety and infection control”

 

  1. The Omnibus Reconciliation Act (OBRA) was enacted to protect patients from unnecessary restraint in long-term care facilities. According to OBRA regulations, one reason to restrain a patient would be if the:
a. Staffing level is inadequate, and nurses are unable to check on the patient at regular intervals.
b. Patient is verbally abusive to the nursing staff.
c. Patient is at an extremely high risk for a fall that is life threatening.
d. Medical procedures cannot be performed because the patient is not being cooperative.

 

ANS: C

The only people who are considered restrainable are those who: (1) are at high risk for a fall that is life threatening; (2) need postural support for safety, comfort, or both; (3) may be a serious hazard to themselves, objects, or others; and, (4) have life-threatening medical symptoms and for whom a restraint may be temporarily used to provide necessary treatment.

 

DIF:   Cognitive Level: Comprehension  REF:  p. 325            OBJ:  4

TOP:  Restraints      KEY: Nursing Process Step: Planning

MSC: “NCLEX: Safe, Effective Care Environment: Coordinated care”

 

  1. The nurse is aware that the patient at greatest risk for injury from falls is the:
a. Toddler
b. Teenager
c. Middle-aged adult
d. Older adult

 

ANS: D

Older adults are at particular risk for accidents because of changes brought about by aging, a greater potential for injury, and poorer clinical outcomes.

 

DIF:   Cognitive Level: Comprehension  REF:  p. 323            OBJ:  3

TOP:  Risk of Falls  KEY: Nursing Process Step: Analysis

MSC: “NCLEX: Safe, Effective Care Environment: Safety and infection control”

 

  1. Where should the patient with a visual impairment of the left eye place items that are frequently used to prevent the risk of injury?
a. On the patient’s left side
b. In the patient’s bathroom
c. In the patient’s closet
d. On the patient’s right side

 

ANS: D

The patient with a visual impairment on one side benefits from having objects placed on the unaffected side and within reach. This placement reduces the risk of falling.

 

DIF:   Cognitive Level: Analysis             REF:  p. 328            OBJ:  5

TOP:  Fall Prevention                              KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Safety and infection control

 

  1. The older adult patient with osteoporosis is at risk for falls. To maintain safety in the home, the nurse would advise the patient to:
a. Take the rubber mat out of the shower.
b. Install a grab rail in the bath and shower and by the toilet.
c. Avoid rubber-soled shoes.
d. Avoid exercise.

 

ANS: B

The patient who is at risk for falls must have rails to hold to prevent falling. A rubber mat in the shower and rubber-soled shoes are important to prevent slipping. Moderate exercise is beneficial.

 

DIF:   Cognitive Level: Comprehension  REF:  p. 330            OBJ:  5

TOP:  Fall Prevention                              KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Safety and infection control

 

  1. The nurse assesses a resident in a long-term care facility with the “Get Up and Go” technique, which involves observing the resident:
a. Walk carefully through a cluttered area without incident.
b. Rise from the bed, and go to the bathroom.
c. Sit and rise from an armless chair.
d. Ambulate in a straight line for 1 foot.

 

ANS: C

The “Get up and Go” technique of evaluation requires that the resident be able to sit and rise from an armless chair.

 

DIF:   Cognitive Level: Application        REF:  p. 326            OBJ:  6

TOP:  Fall Prevention                              KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic care and comfort

 

  1. The nurse is discussing the risk of falling with the family of a 75-year-old patient. The family asks, “Why are you so worried about her falling? She falls all the time and doesn’t get hurt much.” The nurse’s response will be related to the fact that:
a. Falls are the most frequent cause of accidental injury and death among older adults.
b. Worrying is probably unnecessary because she hasn’t been hurt in the past.
c. Falls usually occur in institutional settings.
d. Falls by older adults are not preventable.

 

ANS: A

The risk of injury from falls is highest in people older than 65 years, and falls are the most frequent cause of accidental injury and death among older adults. Older adults account for 72% of total deaths resulting from falls.

 

DIF:   Cognitive Level: Comprehension  REF:  p. 323            OBJ:  2

TOP:  Incidence of Falls                          KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe Effective Care Environment: Safety and infection control

 

  1. A patient with Parkinson disease would be at risk for falling as a result of:
a. Quick movements
b. Unsteady, shuffling gait
c. Hemiparesis
d. Frequent loss of consciousness

 

ANS: B

The patient with Parkinson disease has a very unsteady shuffling gait, as well as a very slow response, which could cause the patient to fall.

 

DIF:   Cognitive Level: Analysis             REF:  p. 325            OBJ:  3

TOP:  Risk of Falls  KEY: Nursing Process Step: Assessment

MSC: “NCLEX: Safe, Effective Care Environment: Safety and infection control”

 

  1. The nurse visiting a patient in the patient’s home assesses the environment for extrinsic risk factors for falling. The nurse should have the patient or family correct which one of the following?
a. No door thresholds are present.
b. The kitchen floor is clean, shiny, and slick.
c. Lamps have 60-watt bulbs.
d. The telephone is placed on the bedside table.

 

ANS: B

Slick floors can cause the patient to slip and fall. The other choices are implementations that will help reduce the risk of falls.

 

DIF:   Cognitive Level: Application        REF:  p. 329            OBJ:  3

TOP:  Fall Prevention                              KEY: Nursing Process Step: Planning

MSC: “NCLEX: Safe, Effective Care Environment: Safety and infection control”

 

  1. The nurse is teaching the patient methods for getting up after a fall. The nurse instructs the patient to pull up to a sitting position on the floor, shuffle the buttocks to a nearby piece of furniture, pull up on the knees in front of the furniture, and then:
a. Stand up.
b. Place hands on the floor for leverage.
c. Pivot so that the furniture is behind the body.
d. Sit back down.

 

ANS: A

The last step of the shuffle method is to stand up.

 

DIF:   Cognitive Level: Application        REF:  p. 330            OBJ:  6

TOP:  Getting Up after a Fall                   KEY: Nursing Process Step: Planning

MSC: NCLEX: Health Promotion and Maintenance: Safety and infection control

 

  1. Family members who brought a patient to the emergency department after she had fallen in her home are expressing their feelings of guilt. The nurse’s most therapeutic response to the family would be:
a. “Someone should really be staying with her to prevent her from falling.”
b. “Let me see how long it will be before you can see the patient.”
c. “Don’t worry. You have nothing to feel guilty about.”
d. “I can see you are worried.”

 

ANS: D

This choice presents therapeutic communication and uses the technique of clarifying.

 

DIF:   Cognitive Level: Application        REF:  p. 330            OBJ:  6

TOP:  When a Fall Occurs                       KEY: Nursing Process Step: Implementation

MSC: NCLEX: Psychosocial Integrity: Coping and adaptation

 

  1. The nurse is aware that many residents in a long-term care facility refuse to wear the hip protector garment and use, as their excuse, that the garment is:
a. Uncomfortable
b. Too expensive
c. Degrading
d. Too easily soiled

 

ANS: A

Residents resist wearing the hip protector garment because it is uncomfortable.

 

DIF:   Cognitive Level: Knowledge        REF:  p. 328            OBJ:  5

TOP:  Hip Protector Garment                  KEY: Nursing Process Step: Planning

MSC: NCLEX: Safe Effective Care Environment: Safety and infection control

 

  1. The home health nurse recommends to a patient that if a fall occurs at home, the patient should:
a. Assume a crawling position and push up from the floor.
b. Pull self up using sturdy furniture.
c. Roll to a doorway, and pull up using the door knob.
d. Place the right foot flat on floor, and push up on right knee.

 

ANS: B

All techniques for rising after a fall rely on pulling up on sturdy furniture.

 

DIF:   Cognitive Level: Comprehension  REF:  p. 330            OBJ:  6

TOP:  Rising after a Fall                          KEY: Nursing Process Step: Planning

MSC: NCLEX: Health Promotion and Maintenance: Prevention and early detection of disease

 

  1. Following the “Rule of Least Restriction,” the nurse who is trying to keep a confused resident from removing the feeding tube would replace the wrist restraint with:
a. Mittens
b. Vest restraint
c. Administration of a mild sedative
d. Tightly tucked sheet

 

ANS: A

Mittens are the lesser of restraints that will hinder the patient from removing the feeding tube.

 

DIF:   Cognitive Level: Comprehension  REF:  p. 325            OBJ:  7

TOP:  Restraints      KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic care and comfort

 

MULTIPLE RESPONSE

 

  1. The nurse points out that people who have a fear of falling may alter their lifestyle to the point that they: (Select all that apply.)
a. Restrict their physical activities.
b. Restrict their social activities.
c. Become more dependent.
d. Have increased need for residency in a long-term care facility.
e. Become depressed.

 

ANS: A, B, C, D

Restricting physical and social activities, becoming more dependent and having an increased need for residency in a long-term-care facility all have to do with an altered lifestyle. The development of depression is not a lifestyle alteration but may be a result of the lifestyle change.

 

DIF:   Cognitive Level: Analysis             REF:  p. 323            OBJ:  3

TOP:  Fear of Falls  KEY: Nursing Process Step: Implementation

MSC: NCLEX: Psychosocial Integrity: Coping and adaptation

 

  1. The home health nurse cautions the family of a frail 82-year-old woman about the intrinsic factors that may be a potential cause of injury. These are: (Select all that apply.)
a. Diminished vision
b. Pet cats
c. Cluttered bedroom
d. Wearing loose house slippers
e. Generalized weakness

 

ANS: A, E

Diminished vision and generalized weakness are the only options related to the individual that cannot be changed (intrinsic). The other options are related to the environment and can be changed (extrinsic).

 

DIF:   Cognitive Level: Analysis             REF:  p. 324            OBJ:  5

TOP:  Intrinsic Factors                             KEY: Nursing Process Step: Planning

MSC: NCLEX: Health Promotion and Maintenance: Safety and infection control

 

COMPLETION

 

  1. The nurse is aware that of all the reported falls in the United States, only 1% to 5% result in a ____________________.

ANS:

Fracture

According to reported falls, only 1% to 5% result in a fracture.

 

DIF:   Cognitive Level: Knowledge        REF:  p. 324            OBJ:  2

TOP:  Incidence       KEY: Nursing Process Step: N/A            MSC: NCLEX: N/A

 

  1. The nurse helps the physical therapist teach residents in a long-term care facility how to diminish the risk of injury from a fall by teaching them rotation maneuvers to help them avoid falling ____________________.

ANS:

Sideways

Rotation maneuvers can be taught to patients to help them avoid falling sideways.

 

DIF:   Cognitive Level: Application        REF:  p. 330            OBJ:  5

TOP:  Fall Prevention                              KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Coordinated care

 

  1. The nurse suggests that a resident who is at risk for falling come to the ________ ________ class to improve balance.

ANS:

Tai Chi

The slow rhythmic movements of Tai Chi are helpful in improving balance.

 

DIF:   Cognitive Level: Knowledge        REF:  p. 328            OBJ:  9

TOP:  Tai Chi          KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological adaptation

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