A home health care nurse is conducting a fall risk assessment for a client who has osteoarthritis and lives alone. The nurse should identify that which of the following factors creates a risk for falls?

Large pieces of furniture.

A bedside table next to the bed.

Raised toilet seats.

Throw rugs on hardwood floors.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Large pieces of furniture do not necessarily create a significant risk for falls unless they are poorly placed or obstructing pathways. While they can potentially cause accidents, the likelihood of tripping over them is generally lower compared to other hazards.

Choice B rationale:

A bedside table next to the bed is not a significant fall risk factor. In fact, having a bedside table can be beneficial for the client, as it provides a convenient surface for placing items that the client might need during the night.

Choice C rationale:

Raised toilet seats, although they may pose a challenge for individuals with mobility issues, are typically installed to aid those with difficulty sitting down or standing up. They are not a primary risk factor for falls, especially when compared to other more hazardous factors.

Choice D rationale:

Throw rugs on hardwood floors are a significant fall risk factor, especially for older adults or individuals with mobility problems. The rugs can easily shift or bunch up, causing someone to trip and fall. Hardwood floors can also become slippery, and the combination of a throw rug on such a surface increases the risk of accidents. The rationale behind this choice is grounded in the potential for tripping and slipping hazards that these throw rugs can introduce, especially in individuals who might already have balance or mobility issues.

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Correct Answer is D

Explanation

Choice A rationale:

Dysrhythmia refers to irregular heart rhythms and is not associated with the carotid artery. It involves issues with the heart's electrical conduction system.

Choice B rationale:

A cardiac murmur is an abnormal sound heard during the heartbeat cycle, usually indicating turbulent blood flow across heart valves. It's not directly related to the carotid artery.

Choice C rationale:

Hypotension refers to low blood pressure, which might impact blood flow through the carotid artery but wouldn't directly cause the sound known as a bruit.

Choice D rationale:

A bruit heard while auscultating the carotid artery suggests a narrowed arterial lumen. A bruit is a whooshing or blowing sound caused by turbulent blood flow due to arterial narrowing or blockage.

A. "The nurse can adjust my mother's pain medication as needed.". B. "We are responsible for obtaining support services for our mother during this process.". C. "My mother would be able to live longer if we decide to use these services.". D. "The doctor will make all decisions about my mother's care.".

Correct Answer is B

Explanation

Choice A rationale:

The family member understanding that the nurse can adjust the mother's pain medication as needed indicates an understanding of the nurse's role in managing the patient's symptoms. However, this statement does not demonstrate an understanding of end-of-life care as a holistic process involving various aspects beyond pain management.

Choice B rationale:

This choice reflects a comprehensive understanding of end-of-life care. The family's responsibility to obtain support services shows awareness of the need for a multidisciplinary approach to address physical, emotional, and practical needs during this process. End-of-life care is a collaborative effort, and this choice accurately acknowledges the role of the family in coordinating necessary services.

Choice C rationale:

The statement about prolonging the patient's life through services reflects a misconception about end-of-life care. The focus of end-of-life care is on improving the quality of life and managing symptoms rather than attempting to extend life. This choice suggests a lack of understanding about the terminal nature of the illness.

Choice D rationale:

Believing that the doctor will make all decisions about the patient's care might indicate a lack of involvement or shared decision-making in the care process. End-of-life care often involves discussions among the medical team, patients, and their families to ensure that the patient's wishes and preferences are respected.

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A home health care nurse is conducting a fall risk assessment for a client who has osteoarthritis and lives alone. The nurse should identify that which of the following factors creates a risk for falls?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is auscultating a client's carotid artery while performing a focused cardiac assessment and hears a bruit. The nurse should identify this finding as a manifestation of which of the following conditions?

Correct Answer is D

Explanation

A nurse is teaching the family of a client who has a terminal illness about end-of-life care. Which of the following statements by a family member indicates an understanding of the teaching?

Correct Answer is B

Explanation

A nurse receives a telephone call from a client's family member, who asks the nurse for an update on the client's condition. Which of the following actions should the nurse take to maintain the client's confidentiality?

A nurse is preparing to administer diazepam 2 mg twice daily via NG tube. Available is diazepam oral solution 5 mg/1 mL. How many mL should the nurse administer with each dose?

A nurse is receiving change-of-shift report for four clients. Which of the following clients should the nurse assess first?

A nurse is preparing to assign tasks to an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?

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A nurse is inserting an NG tube for a client who has a new prescription for enteral feedings. Which of the following actions should the nurse take to verify the placement of the client's tube? (Select all that apply.).

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