Gerontological Nurse Test Falls Prevention and Safety in the Elderly 1 — Questions and Answers
Question 1: Which standardized tool is most widely used in clinical settings to assess fall risk in hospitalized older adults?
- Braden Scale
- Morse Fall Scale (Correct answer)
- Norton Scale
- Glasgow Coma Scale
Correct answer: Morse Fall Scale
The Morse Fall Scale assesses six risk factors—fall history, secondary diagnosis, ambulatory aids, IV therapy, gait, and mental status—to quantify fall risk in hospitalized patients.
Question 2: An older adult reports a fear of falling that has caused them to restrict their activities. The nurse recognizes this as:
- Appropriate and adaptive caution that should be encouraged
- Post-fall syndrome, which can lead to deconditioning and increased fall risk (Correct answer)
- A normal part of aging that requires no intervention
- Anxiety disorder requiring psychiatric evaluation
Correct answer: Post-fall syndrome, which can lead to deconditioning and increased fall risk
Fear of falling leading to activity restriction creates a vicious cycle of deconditioning, muscle weakness, and balance deterioration that paradoxically increases fall risk.
Question 3: Which type of exercise has the strongest evidence for reducing fall risk in community-dwelling older adults?
- Aerobic exercise only
- Balance and strength training exercises such as Tai Chi (Correct answer)
- Swimming and water aerobics exclusively
- Stretching and flexibility exercises alone
Correct answer: Balance and strength training exercises such as Tai Chi
Tai Chi and other balance and strength training programs have robust evidence for reducing fall frequency and improving postural stability in older adults.
Question 4: A nurse is performing a home safety assessment for an older adult at risk for falls. Which finding requires the most urgent intervention?
- A non-slip bath mat in the shower
- Loose throw rugs throughout the hallways (Correct answer)
- Night lights installed in the bedroom and hallway
- Grab bars installed beside the toilet
Correct answer: Loose throw rugs throughout the hallways
Loose throw rugs are a major fall hazard because they can slip, bunch, or catch a shuffling foot; removing them is an immediate and high-priority intervention.
Question 5: Orthostatic hypotension is a significant fall risk factor in older adults. It is defined as a drop of at least:
- 5 mmHg systolic or 3 mmHg diastolic upon standing
- 20 mmHg systolic or 10 mmHg diastolic within 3 minutes of standing (Correct answer)
- 30 mmHg systolic or 15 mmHg diastolic upon sitting
- 10 mmHg systolic or 5 mmHg diastolic upon standing
Correct answer: 20 mmHg systolic or 10 mmHg diastolic within 3 minutes of standing
Orthostatic hypotension is defined as a systolic BP decrease of ≥20 mmHg or diastolic decrease of ≥10 mmHg within three minutes of moving from lying or sitting to standing.
Question 6: Which patient factor is the single strongest predictor of future falls in an older adult?
- Age older than 80 years
- History of one or more previous falls (Correct answer)
- Female sex
- Diagnosis of osteoporosis
Correct answer: History of one or more previous falls
A history of previous falls is the strongest single predictor of future falls, making fall history a critical component of every older adult assessment.
Gerontological Nurse Test Falls Prevention and Safety in the Elderly 1
Which standardized tool is most widely used in clinical settings to assess fall risk in hospitalized older adults?