TOWARD HEALTHY AGING, 11TH
EDITION CHAPTER 20: FALLS AND
FALL RISK REDUCTION QUESTIONS
AND ANSWERS WITH SOLUTIONS 2024
1. Which attempt by the family to prevent an older, frail adult from falling causes the home health nurse
concern?
a. Keeping several low wattage night-lights on in the evening
b. Installing wooden railings on the stairway to the bathroom
c. Keeping the side rails up on the client's bed at night
d. Encouraging the client to use a cane when ambulating - ANSWER ANS: C
Keeping side rails up have proven to be a risk factor for falls rather than a positive intervention. The
remaining interventions are appropriate and generally effective.
2. An 88-year-old admitted to the hospital with a diagnosis of pneumonia has a history of hypertension
and congestive heart failure and is on a total of five different medications for these chronic conditions.
The nurse caring for the patient develops a care plan that includes the diagnosis Risk for Falls. Which
would be a priority nursing intervention for this client?
a. Performing a fall assessment.
b. Keeping all of the side rails up on the client's bed at nighttime.
c. Placing the client on bed rest to minimizing falling.
d. Assessing the client's dietary intake for calcium adequacy. - ANSWER ANS: A
Completing a fall assessment will enable the nurse to identify and correct the risk factors for this patient.
Side rails have not been found to be effective in keeping a client in bed and may actually lead to injury.
Maintaining a patient on bed rest can lead to deconditioning and actually contribute to falls. Assessing
the client's dietary intake of calcium is a good intervention for this age-group, but it is not a priority and
will not prevent falls.
3. A nurse is assessing an older adult's risk for falls. One of the questions asked is whether the older
adult has fallen in the past year. What is the reason behind asking this question?
, a. The risk of falling again is greater for persons who have fallen in the past year.
b. They are more likely to sustain injuries if they fall again than persons who did not fall in the past year.
c. They have most likely developed a fear of falling as compared to persons who did not fall in the past
year.
d. The risk of a balance disorder is greater compared to persons who did not fall in the past year. -
ANSWER Ans, A
A history of falls is an important risk factor and individuals who have fallen have three times the risk of
falling again than persons who did not fall in the past year. There is no evidence to support the other
three options.
4. A nurse is admitting and orienting an older adult to the hospital unit. She discusses fall prevention and
demonstrates the use of the call bell to the patient. The patient's daughter asks: "Why don't you just put
up all the side rails to prevent my mother from getting out of bed by herself and falling. That should
work, right?" What is the nurse's best response?
a. "Side rails have only proven to be effective in decreasing falls in patients who have already fallen."
b. "There is no evidence that side rail use decreases falls, and in fact, there is a greater risk of injury."
c. "Side rails are only effective when used with patients who have dementia."
d. "Side rails do not decrease falls, but they do decrease fall-related injuries." - ANSWER ANS: B
There is no evidence to date that side rail use decreases the risk or rate of fall occurrence. There are
numerous reports and studies documenting the negative effects of side rail use, including entrapment
deaths and injuries that occur when the person slips through the side rail bars or between split side rails,
the side rail and the mattress, or between the head or footboard, side rail, the mattress, or between the
head or footboard, side rail, and mattress.
5. A nurse in a long-term care facility notes that there has been an increase in falls on one unit and that
many of the falls are occurring immediately following mealtime. The nurse recommends that the nursing
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