CNA Preventing Patient Falls and Injuries 3 — Questions and Answers
Question 1: A patient who is confused attempts to climb over the bed rail. What is the BEST immediate intervention?
- Apply a vest restraint immediately
- Stay with the patient, calmly reorient them, and notify the nurse (Correct answer)
- Lower the bed and leave the side rail up on one side only
- Ask a family member to sit with the patient
Correct answer: Stay with the patient, calmly reorient them, and notify the nurse
The CNA should stay with the confused patient to prevent injury, attempt reorientation, and notify the nurse for further assessment and orders.
Restraints require a physician order and are a last resort due to serious risks including injury, pressure ulcers, and psychological harm. The CNA's immediate role is to provide a calming presence, ensure the patient is safe, attempt verbal reorientation, and promptly notify the charge nurse for clinical decision-making.
Question 2: How should a CNA document a patient fall?
- Write a brief note in the patient's personal journal
- Complete the facility's incident report and document in the medical record per facility policy (Correct answer)
- Tell the charge nurse verbally — documentation is the nurse's responsibility
- Record only if an injury occurred
Correct answer: Complete the facility's incident report and document in the medical record per facility policy
All falls must be documented in an incident report and the medical record regardless of injury, per facility policy and regulatory requirements.
Incident reports and medical record documentation create a legal and clinical record. They trigger a review of the patient's fall risk assessment, care plan modification, and may be required for regulatory compliance. CNAs are responsible for completing their part of the documentation promptly and accurately.
Question 3: Which patient characteristic most significantly increases fall risk?
- Age over 65
- History of previous fall (Correct answer)
- Female gender
- Diagnosis of hypertension
Correct answer: History of previous fall
A history of previous falls is the single strongest predictor of future falls and is used in most fall risk assessment tools.
While age, gender, and chronic conditions all contribute to fall risk, prior fall history is consistently the highest-weighted factor in validated tools like the Morse Fall Scale and Hendrich II. A patient who has fallen once has demonstrated the combination of physical, cognitive, and environmental risk factors that produced the first fall.
Question 4: Where should a call light always be positioned for a patient who is in bed?
- On the bedside table across the room
- Clipped to the bed rail within easy reach of the patient's dominant hand (Correct answer)
- At the nurses' station
- On the windowsill for accessibility
Correct answer: Clipped to the bed rail within easy reach of the patient's dominant hand
The call light must be within easy reach so the patient can summon assistance before attempting to get up independently.
Positioning the call light within arm's reach of the patient's dominant hand ensures they can request assistance rather than attempting to get up alone. The CNA should verify call light placement after every patient interaction and before leaving the room.
Question 5: A patient tells you they slipped but did not fall. What should you do?
- Reassure the patient and continue with your duties
- Report the near-fall to the nurse and document it per facility policy (Correct answer)
- Note it in the patient's personal log only
- Increase their pain medication to reduce anxiety
Correct answer: Report the near-fall to the nurse and document it per facility policy
Near-falls are precursor events that warrant care plan review and may prevent a future actual fall.
Near-falls signal that the patient's current fall prevention interventions may be insufficient. Reporting to the nurse triggers reassessment of the fall risk score and care plan adjustments. Many facilities require incident reporting for near-falls just as for actual falls.
Question 6: Which footwear is safest for an ambulating patient?
- Thick wool socks for warmth
- Bare feet for better floor sensation
- Non-skid soled slippers or shoes that fit properly (Correct answer)
- Loose hospital-issued slippers
Correct answer: Non-skid soled slippers or shoes that fit properly
Non-skid footwear that fits properly reduces slipping while also preventing trip hazards from ill-fitting footwear.
Smooth-soled or oversized footwear substantially increases slip and trip risk. Non-skid soles provide traction on common floor surfaces while a proper fit prevents the footwear from catching or falling off. CNAs should ensure patients wear appropriate footwear before any ambulation.
CNA Preventing Patient Falls and Injuries 3
A patient who is confused attempts to climb over the bed rail.
What is the BEST immediate intervention?