A home health nurse is performing a fall risk assessment for an older adult client. Which of the following findings should the nurse identify as a potential fall risk in the home?
The client has electrical wires secured to baseboards.
The client wears rubber-sole shoes.
The client's visual acuity is 20/40.
The client takes an antihypertensive medication.
The Correct Answer is D
A. Securing electrical wires reduces tripping hazards and promotes safety.
B. Rubber-sole shoes provide better traction and reduce the risk of slips and falls.
C. Reduced visual acuity increases the risk of falls but not as much as taking antihypertensives do.
D. Taking an antihypertensive medication can be a potential fall risk, because it can cause hypotension and dizziness.

Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Using a straw can increase the risk of aspiration for clients with dysphagia; thickened liquids should be consumed from a cup.
B. Taking breaks during meals can aid in swallowing and reduce the risk of aspiration.
C. Elevating the head of the bed to 90° helps prevent aspiration during swallowing.
D. Tucking the chin can help close off the airway during swallowing, reducing the risk of aspiration.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}
Explanation
A. Despite the client reporting thirst and frequent urination, the client's urine specific gravity of 1.010 is within the normal range (1.005 to 1.030). The above symptoms could be associated with the hyperglycemia.
B. There is no indication of a pneumothorax in the nurse's notes or diagnostic results.
C. The casual glucose level of 300 mg/dL is significantly above the normal range (less than 200 mg/dL), indicating hyperglycemia.
D. The client’s WBC level is elevated, 11,500/mm3 (5,000 to 10,000/mm3) thus indicating an infection.
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