Answer: b. Implementing regular safety inspections of the facility. Explanation: Regular safety inspections help identify potential hazards and ensure a safe environment for clients, reducing the risk of falls and promoting overall safety.

Incorrect choices: a. Encouraging clients to walk independently without assistance may increase the risk of falls if they have mobility issues or require assistance.

C. Administering sedative medications can potentially increase the risk of falls as it may affect the client's alertness and coordination.

d. Allowing clients to wear loose-fitting clothing may increase the risk of falls due to tripping hazards.

Answer: b. Providing education on fall risk factors and prevention. Explanation: Providing education on fall risk factors and prevention measures is a primary prevention strategy aimed at preventing falls before they occur by increasing awareness and implementing preventive measures.

Incorrect choices: a. Assisting clients with mobility and transfers is an example of secondary prevention, which focuses on minimizing the impact of falls once they occur.

c. Installing handrails in bathrooms and hallways is an example of environmental modification, which is a secondary prevention strategy.

d. Using bed alarms to monitor client movement is an example of secondary prevention, aimed at detecting falls or attempted movement to prevent injury.

Answer: c. "I'll ask for assistance when reaching for items on high shelves." Explanation: Asking for assistance when reaching for items on high shelves demonstrates an understanding of fall prevention by recognizing the need for assistance to avoid potential falls.

Incorrect choices: a. "I prefer walking alone without using my walking aid" indicates a potential disregard for safety and an increased risk of falls.

b. "I'll keep my room dark to improve sleep quality" may increase the risk of falls as adequate lighting is necessary for safe movement.

d. "I'll wear high-heeled shoes for special occasions" increases the risk of falls due to the instability and decreased balance associated with high-heeled footwear.

d. Restricting client mobility to prevent falls.

Answer: a. Identifying clients at risk of falling. Explanation: The primary goal of fall risk assessment is to identify clients who are at risk of falling, enabling healthcare providers to implement appropriate fall prevention strategies.

Incorrect choices: b. Implementing bed restraints for high-risk clients is a secondary prevention strategy and may have negative physical and psychological consequences.

c. Administering sedative medications may increase the risk of falls rather than prevent them.

d. Restricting client mobility without addressing fall risk factors does not effectively prevent falls and can negatively impact a client's functional independence.

Answer: c. To minimize potential hazards and promote safety. Explanation: Implementing environmental modifications aims to minimize potential hazards, such as removing tripping obstacles, improving lighting, and securing handrails, to create a safe environment and promote fall prevention.

Incorrect choices: a. Restricting client movement and preventing falls is not the purpose of environmental modifications, as they should promote independence and safety.

b. Creating a visually stimulating environment is not the primary goal of fall prevention. Instead, the focus is on creating a safe and hazard-free environment.

d. While encouraging client independence and self-care is important, it is not the primary rationale behind implementing environmental modifications specifically for fall prevention.

Answer: c. Conducting regular safety checks and identifying potential hazards. Explanation: The nurse plays a crucial role in promoting patient safety and fall prevention by conducting regular safety checks to identify potential hazards in the environment and taking appropriate measures to mitigate them.

Incorrect choices: a. Administering medications according to the prescribed schedule is important for patient care, but it does not directly address safety and fall prevention.

b. Providing emotional support to patients and their families is important for overall patient well-being, but it is not specific to safety and fall prevention.

d. Documenting patient vital signs accurately and promptly is necessary for maintaining patient records but is not directly related to safety and fall prevention.

Answer: b. Assessing patient mobility and gait regularly. Explanation: Assessing patient mobility and gait regularly is an example of secondary prevention, aimed at detecting and addressing fall risk factors in patients who may already be at risk.

Incorrect choices: a. Providing handrails in bathrooms and hallways is an example of primary prevention, creating an environment that reduces the risk of falls.

c. Educating patients on the importance of exercise is a primary prevention strategy, promoting overall health and reducing the risk of falls.

d. Assisting patients with activities of daily living (ADLs) is a secondary prevention strategy, helping to minimize the impact of falls by providing necessary support.

Answer: b. Medication side effects. Explanation: Medication side effects, such as dizziness, confusion, and orthostatic hypotension, are among the most common causes of falls in healthcare settings.

Incorrect choices: a. Poor lighting in patient rooms can contribute to falls, but it is not the most common cause.

c. Slippery floors due to spills are a potential hazard but are not the most common cause of falls.

d. Inadequate patient education can contribute to falls, but it is not the most common cause.

Answer: c. "I will wear non-slip footwear with good support." Explanation: Wearing non-slip footwear with good support is a fall prevention strategy that helps improve stability and reduce the risk of falls.

Incorrect choices: a. Limiting fluid intake to avoid frequent bathroom trips can lead to dehydration and is not a recommended fall prevention strategy.

b. Using a cell phone while walking can distract the individual and increase the risk of falls.

d. Preferring to walk alone without any assistance disregards safety and increases the risk of falls, especially if there are mobility issues.

Answer: b. To empower patients to take an active role in their own safety. Explanation: The primary goal of patient education regarding fall prevention is to empower patients with knowledge and skills to actively participate in their own safety and make informed decisions to prevent falls.

Incorrect choices: a. Ensuring patient compliance with safety protocols is important but not the primary goal of patient education.

c. Promoting awareness of fall prevention in the community is a broader goal but not the primary focus of patient education.

d. While reducing healthcare costs associated with falls is a desired outcome, it is not the primary goal of patient education for fall prevention.

Answer: c. History of previous falls. Explanation: A history of previous falls is a significant risk factor for falls in older adults. It indicates a higher likelihood of fall incidents and the need for fall prevention interventions.

Incorrect choices: a. Increased muscle strength and flexibility can actually reduce the risk of falls, so it is not a risk factor.

b. Normal visual acuity is important for identifying environmental hazards, but it is not a significant risk factor for falls.

d. Chronic health conditions can increase the risk of falls, so the absence of chronic health conditions would not be a risk factor.

Answer: d. "I will avoid using my walking cane to maintain my balance." Explanation: The use of assistive devices, such as a walking cane, can provide support and help maintain balance, reducing the risk of falls. Avoiding the use of an assistive device when needed indicates a lack of understanding of fall prevention.

Incorrect choices: a. Using handrails when going up and down the stairs is a good practice for maintaining balance and reducing the risk of falls.

b. Removing clutter from walkways and hallways at home helps create a safe environment with fewer trip hazards.

c. Having regular vision checks by an eye care professional is important for identifying and addressing vision-related fall risk factors.

Answer: b. Using bed alarms or chair alarms for patients at risk for falls. Explanation: Bed alarms or chair alarms are appropriate interventions to alert healthcare providers when patients at risk for falls attempt to leave their beds or chairs without assistance, allowing for timely intervention.

Incorrect choices: a. Encouraging patients to ambulate independently without assistance can increase the risk of falls. Assistance should be provided based on the patient's mobility level and fall risk assessment.

c. Keeping patient rooms dimly lit increases the risk of falls. Adequate lighting should be maintained to enhance visibility and safety.

d. Encouraging family members to bring pets to the patient's room for companionship can introduce potential fall hazards and distractions, increasing the risk of falls.

Answer: c. Slip-resistant flooring in high-risk areas. Explanation: Slip-resistant flooring in high-risk areas is an important factor in preventing falls related to environmental hazards. It helps reduce the risk of slips and falls by providing better traction.

Incorrect choices: a. Adequate lighting in patient rooms and hallways is essential to reduce falls related to environmental hazards, not contribute to them.

b. Properly secured handrails on stairways assist with balance and stability, reducing the risk of falls.

d. Regular maintenance of assistive devices, such as canes or walkers, ensures their proper functioning and reduces the risk of falls related to device malfunctions.

Answer: a. Providing clear signage and wayfinding cues. Explanation: Patients with cognitive impairments may experience difficulties navigating their environment. Providing clear signage and wayfinding cues, such as directional arrows or visual cues, can help them safely navigate and reduce the risk of falls.

Incorrect choices: b. Patients with cognitive impairments may require assistance and supervision during ambulation to prevent falls.

c. The use of physical restraints is not recommended for fall prevention as they can lead to adverse effects and compromise patient dignity and mobility.

d. Bed alarms or chair alarms are effective interventions for patients at risk for falls but are not specific to patients with cognitive impairments.

Answer: b. "I will secure the gait belt snugly around the patient's waist." Explanation: When using a gait belt, it should be secured snugly around the patient's waist to provide proper support and prevent slipping or movement during transfers, ensuring patient safety.

Incorrect choices: a. Placing the gait belt over the patient's clothing may result in slippage or reduced effectiveness. It should be placed directly on the patient's waist.

c. Attaching the gait belt to the bed rail compromises the effectiveness of the gait belt and does not provide proper support during transfers.

d. The gait belt is not intended for lifting patients. It is used to provide stability and support during transfers.

Answer: b. Proximity of the bedroom to the bathroom. Explanation: The proximity of the bedroom to the bathroom is an important factor in fall risk assessment as it impacts the ease and safety of accessing the bathroom, especially during nighttime when urgency and limited visibility may increase the risk of falls.

Incorrect choices: a. Availability of advanced medical equipment may not directly contribute to fall risk in the home environment.

c. Distance to the nearest hospital or healthcare facility is not directly related to the risk of falls within the home.

d. Accessibility of outdoor recreational areas may not directly influence fall risk within the home environment.

Answer: c. Locking the wheels of the mechanical lift before transferring the patient. Explanation: Locking the wheels of the mechanical lift ensures stability and prevents movement during patient transfers, reducing the risk of falls.

Incorrect choices: a. Using a sling that is too loose compromises the effectiveness and safety of the mechanical lift. The sling should be properly fitted and secured.

b. Patient transfers using a mechanical lift typically require the assistance of multiple healthcare providers to ensure safety and proper technique.

d. Assessing the patient's weight-bearing status is essential before initiating a transfer to determine the appropriate lift technique and ensure patient safety.

Answer: c. Educating patients about potential side effects of medications. Explanation: Patient education about potential side effects of medications promotes awareness and helps patients recognize and report any adverse effects that may contribute to falls.

Incorrect choices: a. Administering medications with a large glass of water may facilitate swallowing but does not specifically address fall prevention related to medication side effects.

b. Patients should follow healthcare provider instructions for medication administration to ensure accurate and safe dosing. Self-administration should be assessed based on the patient's capability.

d. Mixing multiple medications in a single dose may compromise medication effectiveness and increase the risk of medication errors, but it does not directly address fall prevention related to medication side effects.

Answer: b. Providing nonskid footwear. Explanation: Providing nonskid footwear helps improve traction and stability, reducing the risk of slips and falls in patients with impaired mobility.

Incorrect choices: a. While regular exercise can improve mobility and strength, it should be tailored to the patient's abilities and done with proper supervision. It may not be suitable for all patients with impaired mobility.

c. The use of physical restraints is generally discouraged due to the risk of complications and adverse effects on patient safety and well-being.

d. Encouraging independent ambulation in patients with impaired mobility may not be appropriate and can increase the risk of falls. Assistance should be provided based on the patient's abilities and safety needs.

Answer: c. Securing furniture and equipment to prevent tipping. Explanation: Securing furniture and equipment is important in preventing accidents, such as tip-overs, which can pose a significant risk to pediatric patients.

Incorrect choices: a. Leaving electrical cords and wires in the patient's reach increases the risk of electrical injuries and entanglement hazards.

b. Baby walkers are associated with an increased risk of falls and injuries in pediatric patients and are not recommended.

d. Keeping toys with small parts accessible to all patients increases the risk of choking hazards, especially for younger children who are prone to putting objects in their mouths.

Answer: c. Conducting regular fire drills and staff training. Explanation: Conducting regular fire drills and staff training is an essential part of a comprehensive fire safety plan, promoting preparedness and ensuring appropriate response during fire emergencies.

Incorrect choices: a. Fire exits should never be blocked, as it hinders quick evacuation during emergencies.

b. Fire extinguishers should be easily accessible and properly maintained to facilitate prompt use in case of a fire.

d. Encouraging the use of open flames for aesthetic purposes increases the risk of fire hazards and should be avoided in healthcare facilities.

d. Ensuring the client has adequate lighting in the room.

Answer: b. Encouraging the client to use the call bell for assistance. Explanation: Encouraging the client to use the call bell for assistance is the most important intervention for fall prevention. It promotes the client's involvement in their own safety and ensures that help is readily available when needed.

Incorrect choices: a. Placing a sign on the client's room door indicating fall risk is a helpful visual reminder, but it does not actively prevent falls. c. Providing a nonskid mat on the floor beside the client's bed can reduce the risk of slipping but does not address other factors that contribute to falls. d. Ensuring the client has adequate lighting in the room is important for preventing falls, but it is not the most critical intervention. The client's ability to seek assistance when needed is more crucial.

Answer: c. History of previous falls. Explanation: A history of previous falls is a significant risk factor for future falls. Clients who have fallen before are more likely to fall again, making it a high-risk factor to consider in fall prevention strategies.

Incorrect choices: a. Age over 65 years is a general risk factor for falls but does not provide as much predictive value as a history of previous falls. b. Use of anticoagulant medications increases the risk of bleeding but does not necessarily indicate a higher risk for falls. d. Presence of sensory deficits, such as visual or auditory impairments, can contribute to fall risk but may not be the highest-risk factor compared to a history of previous falls.

Answer: c. Implementing hourly rounding to assess the client's needs. Explanation: Implementing hourlyrounding to assess the client's needs is the most important intervention for preventing falls in a medical-surgical unit. Regular rounding allows the nurse to monitor the client's condition, address any immediate needs, and provide assistance with mobility or other activities, reducing the risk of falls.

Incorrect choices: a. Providing a bedside commode for toileting needs is important for promoting safe toileting, but it does not address the overall risk of falls. b. Placing the client in a private room near the nurses' station may enhance surveillance, but it does not actively prevent falls. d. Educating the client on proper use of assistive devices is essential, but it is not the most critical intervention for fall prevention in the medical-surgical unit setting.

Answer: a. Keeping the client's bed in the lowest position. Explanation: Keeping the client's bed in the lowest position is the most appropriate action to prevent falls. A low bed height reduces the risk of injury if the client accidentally falls out of bed.

Incorrect choices: b. Using bed rails to restrict the client's movement is not recommended as it can increase the risk of entrapment or injury. Bed rails should be used judiciously and with caution. c. Providing the client with nonskid footwear is important for promoting stability and preventing slips and falls, but it is not the most crucial intervention in this scenario. d. Administering sedative medications at bedtime increases the risk of falls by affecting the client's balance and alertness. Sedatives should be used sparingly and only when necessary.

Answer: c. Implementing fall prevention interventions for the client. Explanation: After a fall, the most appropriate action for the nurse is to implement fall prevention interventions for the client. This includes reassessing the client's risk factors, modifying the environment, and providing necessary support and assistance to prevent future falls.

Incorrect choices: a. Documenting the fall incident in the client's medical record is an essential step but should follow the immediate implementation of fall prevention interventions. b. Conducting a comprehensive fall risk assessment is important, but it should be done as part of the ongoing care and assessment rather than immediately after a fall. d. Reporting the fall to the unit manager is necessary for organizational reporting purposes, but it does not directly address the client's immediate safety needs.

Answer: a. "I will make sure to wear my eyeglasses all the time." Explanation: The statement "I will make sure to wear my eyeglasses all the time" indicates a need for further education on fall prevention. While wearing eyeglasses can improve vision, it is not adirect fall prevention measure. It is important for the client to address other risk factors such as environmental hazards, balance, and mobility.

Incorrect choices: b. "I will use the handrails when going up and down the stairs." This statement demonstrates an understanding of using handrails for support and stability while navigating stairs, which is an appropriate fall prevention measure. c. "I will ask for help when I need to use the bathroom at night." This statement reflects the client's awareness of the need to seek assistance when necessary, reducing the risk of falls during nighttime bathroom visits. d. "I will keep my room well-lit during the day and night." This statement indicates an understanding of the importance of adequate lighting to enhance visibility and prevent falls in the client's room.

the client with a bed alarm system. d. Recommending the use of a cane or walker.

Answer: d. Recommending the use of a cane or walker. Explanation: Recommending the use of a cane or walker is the most appropriate intervention for an older adult client at risk for falls. Assistive devices can provide additional support and stability, helping to maintain balance and reduce the risk of falls.

Incorrect choices: a. Implementing a toileting schedule for the client is important but may not directly address the client's specific fall risk. b. Assessing the client's orthostatic blood pressure is essential for assessing orthostatic hypotension but may not be the most appropriate intervention for addressing fall risk in this scenario. c. Providing the client with a bed alarm system can help alert the nursing staff when the client is attempting to leave the bed, but it does not directly address the client's balance and stability needs.

Answer: a. Removing tripping hazards from the client's environment. Explanation: Removing tripping hazards from the client's environment is the most important intervention for preventing falls. It helps create a safe and hazard-free environment, reducing the risk of accidental falls.

Incorrect choices: b. Providing the client with nonskid footwear is important for promoting stability and preventing slips and falls but may not address all potential fall risks. c. Educating the client on the correct use of handrails is essential, but it may not be the most critical intervention compared to removing environmental hazards. d. Assisting the client with toileting and ambulation is important, but it focuses on direct assistance rather than eliminating hazards from the environment.

Answer: a. "I will use a nightlight in my bedroom and bathroom." Explanation: The statement "I will use a nightlight in my bedroom and bathroom" indicates understanding of the need for adequate lighting to prevent falls during nighttime activities.

Incorrect choices: b. "I will make sure to rush to answer thephone." This statement demonstrates a misunderstanding of the importance of prioritizing safety over rushing to answer the phone, which may increase the risk of falls. c. "I will keep my medication bottles on the kitchen counter." This statement suggests a potential hazard of leaving medication bottles on the counter, which can increase the risk of falls due to clutter and potential spills. d. "I will wear socks with a smooth sole for better comfort." This statement indicates a lack of understanding of the importance of wearing nonskid footwear to maintain traction and prevent slips and falls. Smooth-soled socks may increase the risk of slipping on smooth surfaces.