A nurse caring for patients in a long-term care facility knows that there are factors that place certain patients at a higher risk for falls.
Which patients would the nurse consider to be in this category? Select all that apply.

A patient who experiences postural hypotension.

A patient who is experiencing nausea from chemotherapy.

A patient who has already fallen twice.

A patient who is older than 50 years old.

A patient who is transferred to long-term care.

Answer and Explanation

Correct Answer : A,C,E

Choice A rationale
A patient who experiences postural hypotension is at a higher risk for falls. Postural hypotension, or a sudden drop in blood pressure upon standing, can cause dizziness and increase the likelihood of falling. This condition is common in older adults and those with certain medical conditions.
Choice B rationale
A patient who is experiencing nausea from chemotherapy is not necessarily at a higher risk for falls. While nausea can cause discomfort and weakness, it does not directly contribute to an increased risk of falling. Other factors, such as medication side effects or balance issues, are more significant in fall risk assessment.
Choice C rationale

A patient who has already fallen twice is at a higher risk for future falls. A history of falls is a strong predictor of subsequent falls, as it may indicate underlying issues such as balance problems, muscle weakness, or environmental hazards.
Choice D rationale
A patient who is older than 50 years old is not automatically at a higher risk for falls. While age is a factor, the risk significantly increases for individuals over 65 years old. Other factors, such as medical conditions and medication use, play a more critical role in fall risk assessment.
Choice E rationale
A patient who is transferred to long-term care is at a higher risk for falls. The transition to a new environment can be disorienting, and patients may be unfamiliar with their surroundings. Additionally, long-term care patients often have multiple health issues that contribute to an increased fall risk.

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Correct Answer is C

Explanation

Choice A rationale
A common adverse event that occurs frequently is not considered a sentinel event. Sentinel events are rare and unexpected occurrences that result in severe harm or death. Common adverse events, while important to address, do not meet the criteria for sentinel events.
Choice B rationale
A minor incident that does not require reporting is not considered a sentinel event. Sentinel events are serious and significant occurrences that require immediate investigation and response. Minor incidents, while important to address, do not meet the criteria for sentinel events.
Choice C rationale
An unexpected occurrence involving death or serious physical or psychological injury is the definition of a sentinel event. These events are significant and require immediate investigation and response to prevent recurrence. Sentinel events signal the need for a thorough review of the processes and systems involved to identify and address the root causes.
Choice D rationale
A situation where the patient experiences temporary discomfort is not considered a sentinel event. Sentinel events involve severe and lasting harm, such as death or permanent injury.
Temporary discomfort, while important to address, does not meet the criteria for sentinel events.

A. Providing information. B. Confrontation. C. Summarizing. D. Probing.

Correct Answer is A

Explanation

Choice A rationale
Providing information is the communication technique used by the nurse in this scenario. The nurse is giving the patient information about the benefits of taking pain medication before physical therapy, which helps the patient understand and manage their pain effectively.
Choice B rationale
Confrontation involves addressing discrepancies or conflicts directly, which is not what the nurse is doing in this scenario. The nurse is providing information, not confronting the patient.
Choice C rationale
Summarizing involves restating the main points of a conversation to ensure understanding. While the nurse is providing information, they are not summarizing the conversation.
Choice D rationale
Probing involves asking questions to gain more information. The nurse is not asking questions in this scenario but is providing information to the patient.

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A nurse caring for patients in a long-term care facility knows that there are factors that place certain patients at a higher risk for falls. Which patients would the nurse consider to be in this category? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What is a sentinel event in healthcare?

Correct Answer is C

Explanation

Correct Answer is A

Explanation

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A nurse caring for patients in a long-term care facility knows that there are factors that place certain patients at a higher risk for falls.
Which patients would the nurse consider to be in this category? Select all that apply.