Falls Prevention and Safety in the Elderly Flashcards

A nurse is implementing universal fall precautions for all hospitalized older adults. Which intervention is a component of universal fall precautions?

Answer: Ensuring call lights are within reach and beds are in the lowest position

Universal fall precautions include keeping beds in the lowest position, call lights within reach, non-slip footwear provided, and bed brakes locked—applied to all patients regardless of assessed risk level.

Which condition causing gait disturbance significantly increases fall risk in older adults and is characterized by a broad-based, shuffling gait and urinary incontinence?

Answer: Normal pressure hydrocephalus (NPH)

Normal pressure hydrocephalus presents with the classic triad of gait disturbance (magnetic gait), urinary incontinence, and cognitive decline, and is a treatable cause of falls in older adults.

A nurse is assessing an older adult's vision as part of a fall risk evaluation. Which visual change associated with aging most directly increases fall risk?

Answer: Reduced contrast sensitivity and depth perception

Reduced contrast sensitivity impairs the ability to detect edges and surface changes, while decreased depth perception makes it difficult to judge distances and step heights, both directly contributing to falls.

An older adult with a history of falls is started on a new antihypertensive. The nurse should prioritize teaching the patient to:

Answer: Rise slowly from sitting or lying positions and sit at the bedside before standing

Antihypertensives can cause or worsen orthostatic hypotension; teaching patients to change positions slowly allows time for compensatory cardiovascular adjustments and reduces fall risk.

Hip protector pads are a secondary fall prevention strategy designed to:

Answer: Reduce the risk of hip fracture if a fall does occur

Hip protectors are secondary prevention devices that absorb or deflect impact forces during a fall, reducing hip fracture risk without preventing the fall itself.

Which assessment finding in an older adult requires the nurse to immediately implement fall precautions beyond universal measures?

Answer: Patient scores 45 or above on the Morse Fall Scale

A Morse Fall Scale score of 45 or above indicates high fall risk, triggering enhanced fall precautions such as increased monitoring, bed alarms, and closer supervision during ambulation.