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 A
Explanation
A. Costs associated with services are a direct barrier to accessing resources, as financial constraints can prevent individuals from utilizing available services.
B. Insufficient staffing at local clinics affects service availability but is not a barrier to referring to external resources.
C. Inadequate knowledge of resources is an informational barrier rather than a resource barrier.
D. Decreased motivation is related to individual behavior and not to the barriers associated with accessing resources.
Correct Answer is A
Explanation
A. "Apply clean gauze pads over the client's open eyes to prevent damage." This is appropriate. Closing the client's eyes and placing gauze pads over them helps to prevent drying and damage, maintaining a respectful appearance of the deceased.
B. "Place the dentures in a bag that is clearly marked with the client's name." This is incorrect. While it is important to handle personal items with respect, this option is less relevant to postmortem care compared to the other options.
C. "Remove the client's urinary catheter ensuring that the perineum is clean." This is incorrect. If the client is on home hospice care and has just died, it is generally not necessary to remove the urinary catheter unless specifically required by the hospice protocols.
D. "Secure the client's upper extremities by tying them together over the abdomen." This is incorrect and inappropriate. Tying extremities is not a standard practice and does not align with respectful postmortem care.
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