A home health nurse is educating a student nurse about fall risk factors in the home. Which client would the student identify as having the highest risk of falling, demonstrating understanding of the teaching?
A 68-year-old client with stage 2 thyroid cancer who takes levothyroxine daily
An 82-year-old client with diabetes mellitus who takes metformin daily
A 78-year-old client with decompensated heart failure who is dyspneic on exertion
A 74-year-old client with hypertension taking lisinopril
The Correct Answer is C
A. Although thyroid cancer and medication use can affect health, they are not the most immediate factors influencing fall risk compared to heart failure symptoms.
B. Diabetes mellitus and metformin use are not directly associated with increased fall risk as much as heart failure and its symptoms.
C. Decompensated heart failure and dyspnea on exertion significantly increase fall risk due to decreased physical stability and balance issues.
D. While hypertension and lisinopril can contribute to fall risk, they are less directly impactful than the symptoms of decompensated heart failure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","E"]
Explanation
A. Attending support groups is a positive intervention that helps prevent relapse by providing support and accountability, so it is not associated with preceding a relapse.
B. Decreased motivation is a significant risk factor for relapse, as it can lead to a lack of adherence to recovery strategies and a return to old behaviors.
C. Planning a strategy is a proactive measure that helps prevent relapse rather than contributing to it.
D. A negative emotional state can contribute to relapse by increasing stress and making it harder to maintain recovery efforts.
E. Stressful situations are known to trigger relapse by overwhelming individuals and making them more likely to revert to old coping mechanisms.
Correct Answer is A
Explanation
A. The Health Belief Model is illustrated here as the client’s motivation to get a mammogram is based on her belief in the severity of breast cancer and the benefits of early detection to prevent death.
B. Social Learning Theory involves learning through observation and imitation, which is not directly reflected in the client’s decision-making process described.
C. The Theory of Reasoned Action focuses on behavioral intentions based on attitudes and subjective norms, which is less relevant to the client’s belief about the severity of a health condition.
D. The Transtheoretical Model involves stages of change related to behavior modification, which is not directly illustrated by the client’s statement about her motivations for undergoing a mammogram.
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