BSN 205 Final UPDATED ACTUAL Exam
Questions and CORECT Answers
An 80-year-old patient with rheumatoid arthritis is being admitted for a procedure where
injections will be placed in her back to relieve pain. She reports having fallen less than 1 year
ago on icy steps to her house. She is alert and oriented and occasionally uses a cane. She has
never smoked, but takes an antihypertensive medication for her blood pressure. Is this patient at
risk for a fall? - CORRECT ANSWER -Yes
A 48-year-old patient is being admitted for surgery. He is alert and oriented and his gait is
steady. He does not need any ambulatory devices and denies having a recent fall. He wears
glasses. His only medication is an antibiotic for infection. Is this patient a fall risk? - CORRECT
ANSWER -No
An 82-year-old patient is being admitted to the nursing home. Her husband passed away 3
months ago. This patient has fallen twice during that time and has suffered some contusions and
a laceration as a result. She wears a hearing aid and glasses, and she uses a cane when she goes
outside because her knees "get weak." Inside, she holds onto furniture as she ambulates. She is
alert and oriented. Her closest child lives approximately 100 miles away and is in poor health
herself. The patient and her family decided on nursing home placement. What factors place her
at risk for sustaining a fall now that she is a resident of a nursing home? - CORRECT
ANSWER -* Being in an unfamiliar environment
* Use of hearing aids and glasses
* Use of a cane
* History of falling
* Age
There has been an increased number of falls on a busy extended care (recuperative care) unit
over the last 6 months. You, the quality improvement nurse, have decided to conduct a meeting
for the NAPs regarding safety precautions for preventing falls. What should you include in this
in-service? - CORRECT ANSWER -*Keeping the bed locked and in low position
*Keeping the patient's personal items within reach
*Putting nonskid footwear on the patients
*Notifying the nurse of patient behaviors that indicate confusion
, Rationale for performing the timed Get Up and Go Test? - CORRECT ANSWER -
Determines if patient needs assistance with ambulating
Rationale for opening the curtains and look around the patient's room? - CORRECT
ANSWER -Identified environmental risk factors for falls such as poor lighting, cluttered
hallways, wet floors
Rationale for noting that the patient takes an antihypertensive for fall risk? - CORRECT
ANSWER -Specific classes of meds may cause hypotension
Rationale for noting that the patient requires opioids for pain management for fall risk? -
CORRECT ANSWER -Creates risk for patient being drowsy
Rationale for determining whether the patient has glasses or a hearing aid for fall risk? -
CORRECT ANSWER -Sensory impairment increases a patients physical risk factors for
falling
Rationale for assessing patients memory, ability to identify objects, and orientation for fall risk? -
CORRECT ANSWER -Physiological impairments such as impaired cognition increases a
patients risk for falls
What is the purpose of a wedge cushion? - CORRECT ANSWER -A seat belt or wedge
cushion helps prevent the patient from sliding out of the chair.
The NAP is preparing to transfer a patient from a bed to a chair. What equipment should the
NAP have? - CORRECT ANSWER -A gait belt should be used when transferring a patient
from the bed to a chair.
As a student nurse, you are writing a care plan for a hospitalized patient. You have determined
the nursing diagnosis "risk for falls related to unfamiliar environment." You have also developed
the following outcomes: (1) patient and family demonstrate use of call light to obtain assistance,
and (2) patient and family state reasons why safety devices are used. What other expected
Questions and CORECT Answers
An 80-year-old patient with rheumatoid arthritis is being admitted for a procedure where
injections will be placed in her back to relieve pain. She reports having fallen less than 1 year
ago on icy steps to her house. She is alert and oriented and occasionally uses a cane. She has
never smoked, but takes an antihypertensive medication for her blood pressure. Is this patient at
risk for a fall? - CORRECT ANSWER -Yes
A 48-year-old patient is being admitted for surgery. He is alert and oriented and his gait is
steady. He does not need any ambulatory devices and denies having a recent fall. He wears
glasses. His only medication is an antibiotic for infection. Is this patient a fall risk? - CORRECT
ANSWER -No
An 82-year-old patient is being admitted to the nursing home. Her husband passed away 3
months ago. This patient has fallen twice during that time and has suffered some contusions and
a laceration as a result. She wears a hearing aid and glasses, and she uses a cane when she goes
outside because her knees "get weak." Inside, she holds onto furniture as she ambulates. She is
alert and oriented. Her closest child lives approximately 100 miles away and is in poor health
herself. The patient and her family decided on nursing home placement. What factors place her
at risk for sustaining a fall now that she is a resident of a nursing home? - CORRECT
ANSWER -* Being in an unfamiliar environment
* Use of hearing aids and glasses
* Use of a cane
* History of falling
* Age
There has been an increased number of falls on a busy extended care (recuperative care) unit
over the last 6 months. You, the quality improvement nurse, have decided to conduct a meeting
for the NAPs regarding safety precautions for preventing falls. What should you include in this
in-service? - CORRECT ANSWER -*Keeping the bed locked and in low position
*Keeping the patient's personal items within reach
*Putting nonskid footwear on the patients
*Notifying the nurse of patient behaviors that indicate confusion
, Rationale for performing the timed Get Up and Go Test? - CORRECT ANSWER -
Determines if patient needs assistance with ambulating
Rationale for opening the curtains and look around the patient's room? - CORRECT
ANSWER -Identified environmental risk factors for falls such as poor lighting, cluttered
hallways, wet floors
Rationale for noting that the patient takes an antihypertensive for fall risk? - CORRECT
ANSWER -Specific classes of meds may cause hypotension
Rationale for noting that the patient requires opioids for pain management for fall risk? -
CORRECT ANSWER -Creates risk for patient being drowsy
Rationale for determining whether the patient has glasses or a hearing aid for fall risk? -
CORRECT ANSWER -Sensory impairment increases a patients physical risk factors for
falling
Rationale for assessing patients memory, ability to identify objects, and orientation for fall risk? -
CORRECT ANSWER -Physiological impairments such as impaired cognition increases a
patients risk for falls
What is the purpose of a wedge cushion? - CORRECT ANSWER -A seat belt or wedge
cushion helps prevent the patient from sliding out of the chair.
The NAP is preparing to transfer a patient from a bed to a chair. What equipment should the
NAP have? - CORRECT ANSWER -A gait belt should be used when transferring a patient
from the bed to a chair.
As a student nurse, you are writing a care plan for a hospitalized patient. You have determined
the nursing diagnosis "risk for falls related to unfamiliar environment." You have also developed
the following outcomes: (1) patient and family demonstrate use of call light to obtain assistance,
and (2) patient and family state reasons why safety devices are used. What other expected
