Fall (20 Questions)

1.1 Mr. Gignac, an 80-year-old man, was admitted to a CHSLD one week ago due to Alzheimer’s-type major neurocognitive disorder (NCD). While he could follow simple instructions, he frequently forgot recent events. His initial assessment indicated a history of multiple falls at home, and a recent fall risk evaluation confirmed balance issues when standing up.

During the shift report, the night nurse mentioned that Mr. Gignac had pulled his call bell off the wall three times and was found attempting to wrap it around himself. When the nurse checked on him, he had done it again.

Your nursing colleague suggests removing the call bell to prevent further incidents.

Question:
Should you follow your colleague’s suggestion? *
1.2 The next morning, Mr. Gignac experiences a fall while attempting to get up, resulting in a laceration on his left eyebrow. In the afternoon, his daughter is in his room and is concerned about his safety. She asks if the nurse can keep the bed rails raised during his nap to prevent another fall, citing her concern as Mr. Gignac's legal representative.

Question:
Will you follow Mr. Gignac's daughter's request to keep the bed rails raised during his nap? *
1.3 After his afternoon nap, Mr. Gignac shows reluctance to get out of bed. He clings to your uniform sleeve with a frightened look, is stiff, resists standing by bending his knees, and leans his body backward. Clinical examination reveals that he is not in pain.

Question:
What do you suspect is happening to Mr. Gignac? *
2.1 Mrs. McDonald, 89 years old, has been living alone since her husband died six months ago. She was admitted to the medicine unit to have an investigation regarding a loss of autonomy.

During the data collection, her son tells you that he found her with her hair uncombed, no make-up on and in her bathrobe, which is not like her. He said that she has difficulty moving around and that she moves more slowly, which has prevented her from doing her activities for the past week.

During the assessment, Mrs. McDonald says that she fell, three days ago, when she was doing her housework. She did not want to bother her son. An X-ray has been scheduled to rule out a fracture.

When Mrs. McDonald gets up to go to the toilet, she moves slowly. When you ask her if she is in pain, she replies impatiently: “No, no, I’m fine.”

Question:
What do you suspect regarding Mrs. McDonald’s clinical condition and what information is your hypothesis based on? *
2.2 The next day, at 08:15, Mrs. McDonald goes to the washroom and has a fall.

During the physical examination, you assess Mrs. McDonald’s pain using a numeric scale. Mrs. McDonald rates her pain at 3/10. You notice that her non-verbal behaviour does not match the severity of the pain reported.

Question:
What will you do as a priority? *
2.3 Mrs. McDonald is diagnosed with a femoral head fracture. The surgery is scheduled for tomorrow morning.

At 13:15, during your assessment, you observe that Mrs. McDonald is in unbearable pain and that she says she is worried about the surgery tomorrow.

You consult the excerpt from her medication record:
*Hydromorphone (Dilaudid®) 1 mg/tab., 1 tab. (1 mg) PO q 3 h (Last given at 11:00)
*Acetaminophen (Tylenol®) 500 mg/tab., 1 tab. (500 mg) PO q 4 h PRN (Last given at 09:00)
*Hydromorphone (Dilaudid®) 2 mg/ml, 0.125 ml (0.25 mg) subcutaneously q 4 h PRN
*Lorazepam (Ativan®) 0.5 mg/tab., 1 tab. (0.5 mg) SL q 6 h PRN

Question:
Which medication(s) will you administer? Choose TWO (2) answers *
3. Mrs. Dubois is an 82-year-old patient recently admitted to the nursing unit. She has a history of depression and is currently being treated with two prescribed SSRls.

In addition, she is given Ativan (lorazepam) at bedtime (HS) to help with anxiety and insomnia, and Laxaday as needed (PRN) to manage occasional constipation.
Given her advanced age and current medication regimen, the nursing team is preparing a Therapeutic Nursing Plan (TNP) to ensure her safety and well-being during her stay.

Question:
Considering Mrs. Dubois's age, medical history, and current medications, what is the most important risk to address in her Therapeutic Nursing? *
4. Marie Dubois, a 62-year-old female, has recently undergone knee replacement surgery. She has been prescribed Percocet for pain management.
During her postoperative recovery, Marie reported her pain as 7/10. The nurse administered Percocet to alleviate her pain. Marie's vital signs are stable, with a blood pressure of 128/82 mmHg, heart rate of 76 bpm, respiratory rate of 16 breaths/min, temperature of 98.7°F (37°C), and oxygen saturation of 97% on room air. She is alert and oriented, and her incision site appears clean with minimal swelling.

Question:
After administering Percocet for pain, which intervention would be of highest priority for the nurse to complete before leaving the patient's room? *
5.1 Mr. Gérard Tremblay, age 76, was admitted to the hospital following a fall in his apartment. His wife, Mme Ginette Côté, says he had been sleeping more during the day and at times appeared groggy and unsteady at night. He had stood up to go to the bathroom and lost his balance, falling sideways. No head trauma occurred, but he complained of hip pain.
His medical history includes type II diabetes, hypertension, depression, and insomnia.

As per his MAR, he is prescribed the following medications:
Mr. G. Tremblay:
Diabeta (glyburide) – for diabetes
Glucophage (metformin) – for diabetes
Serax (oxazepam) – since the death of his brother
Lopressor (metoprolol) – for hypertension
Celexa (citalopram, an SSRI) – for depression

Medication found in the patient’s drawer that the patient is taking:
Mme Ginette Côté (wife):
Tylenol – over-the-counter, for mild pain
Ativan (lorazepam) – for insomnia

Question:
Which two medications are most likely to have contributed to his fall? *
5.2 As part of his discharge teaching, the nurse must emphasize safe medication practices.

Question
What is the most important teaching the nurse should give Mr. Tremblay? *
6. Mme Boucher, an 82-year-old female with mild dementia, was admitted for a urinary tract infection. She is confused and attempts to climb out of bed frequently. Her daughter arrives, sees her mother trying to stand up, and says to you: "Please put all four side rails up right now so she doesn't fall out of bed!"

Question:
Do you agree to the daughter's request? What is your best response? *
7. You are walking down the hallway and hear a thud in room 302. You enter and find M. Lapointe, 78 years old, lying on the floor beside his bed. He is conscious and moaning.

Question:
What is your priority intervention? *
8. Mme Gagnon, 85 years old, is being admitted for "frequent falls" at home. She brings her bag of medications. You are reconciling her medication list to identify potential causes for her instability.

Medical History: Hypertension, Insomnia, Anxiety.

Question:
Which medication on her list poses the highest risk for falls? *
9. M. Dubé, 75 years old, is recovering from dehydration. He rings the bell to go to the bathroom.

Medical Order: Mobilize with assistance x 1.

When M. Dubé sits up on the edge of the bed, he says, "Whoa, the room is spinning," and he looks pale.

Question:
What is the most appropriate nursing intervention? *
10. You are evaluating Mme Fortin, 80 years old, on her use of a standard walker. She is recovering from left-sided weakness.

Question:
Which observation indicates that Mme Fortin understands the correct technique for using the walker? *
11. M. Beaulieu, 88 years old, is admitted with benign prostatic hyperplasia (BPH). He has fallen twice in the last week during the night. He reports urgent need to urinate multiple times at night.

Question:
Which nursing intervention is most effective to prevent falls for this specific patient? *
13. M. Cloutier, a 74-year-old with Alzheimer’s, continuously gets out of bed and wanders into other patients' rooms. He is unsteady on his feet. The night nurse suggests using a waist belt restraint.

Question:
According to ethical guidelines, what must be attempted before applying the restraint? *
14. You respond to a call bell and find Mme Roy on the floor next to her bed. She is crying and clutching her right hip. She cannot move her leg.

Question:
Which physical assessment finding is most indicative of a hip fracture? *
15. You are preparing M. Lambert for discharge. He lives alone in a two-story house.
Medical Order: Physiotherapy consult for home safety evaluation.

Question:
During your discharge teaching, what is the most common home hazard you should warn M. Lambert about? *