Author Question: The nurse knows the following items should be included in the documentation of the patient on falls ... (Read 63 times)

jwb375 · **on:** Jul 23, 2018

The nurse knows the following items should be included in the documentation of the patient on falls precautions: (Select all that apply.)

a. History of any falls
b. Falls risk assessment scores
c. Patient and family education
d. Use of assist devices
e. Any fall or reported fall

Question 2

The nurse is teaching a patient about ways to decrease her risk of bone fractures. The following statements by the patient indicate a good understanding. (Select all that apply.)

a. I should do weight-bearing exercises.
b. I should get adequate intake of calcium and vitamin D.
c. I should exercise regularly.
d. I need to do yoga exercises.

Kingjoffery · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

ANS: A, B, C, D, E
The nurse should document the general assessment, include the patient's medical history, subjective and objective data, medication review, musculoskeletal status, and history of falls. Falls assessment and reassessment, patient family education and use of assist devices is also documented. Thoroughly document a fall or reported fall, but do not document that an incident report has been filed in the medical record.

Answer to Question 2

ANS: A, B, C
Inadequate dietary intake of calcium and vitamin D or impaired calcium metabolism may result in osteoporosis, which increases bone fragility and may lead to fractures. Decreased physical exercise and lack of weight-bearing exercise also contribute to bone fragility, deterioration, and loss of strength. Any type of exercise will help; it does not need to be yoga, but it does need to include weight-bearing exercise.