A nurse caring for patients in a long-term care facility knows that there are factors that place certain patients at a higher risk for falls.
Which patients would the nurse consider to be in this category? Select all that apply.
A patient who experiences postural hypotension.
A patient who is experiencing nausea from chemotherapy.
A patient who has already fallen twice.
A patient who is older than 50 years old.
A patient who is transferred to long-term care.
Correct Answer : A,C,E
Choice A rationale
A patient who experiences postural hypotension is at a higher risk for falls. Postural hypotension, or a sudden drop in blood pressure upon standing, can cause dizziness and increase the likelihood of falling. This condition is common in older adults and those with certain medical conditions.
Choice B rationale
A patient who is experiencing nausea from chemotherapy is not necessarily at a higher risk for falls. While nausea can cause discomfort and weakness, it does not directly contribute to an increased risk of falling. Other factors, such as medication side effects or balance issues, are more significant in fall risk assessment.
Choice C rationale
A patient who has already fallen twice is at a higher risk for future falls. A history of falls is a strong predictor of subsequent falls, as it may indicate underlying issues such as balance problems, muscle weakness, or environmental hazards.
Choice D rationale
A patient who is older than 50 years old is not automatically at a higher risk for falls. While age is a factor, the risk significantly increases for individuals over 65 years old. Other factors, such as medical conditions and medication use, play a more critical role in fall risk assessment.
Choice E rationale
A patient who is transferred to long-term care is at a higher risk for falls. The transition to a new environment can be disorienting, and patients may be unfamiliar with their surroundings. Additionally, long-term care patients often have multiple health issues that contribute to an increased fall risk.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Encouraging the patient to rely on their knowledge is not sufficient. Patients may not have the necessary understanding or skills to manage a new medication safely. It is important for the nurse to provide comprehensive education on the medication.
Choice B rationale
Reviewing the medication administration technique with the patient ensures they understand how to take the medication correctly. This includes the dosage, timing, and any specific instructions related to the medication. Proper education helps prevent medication errors and promotes adherence to the prescribed regimen.
Choice C rationale
Instructing the patient to avoid contacting healthcare providers with questions is incorrect. Patients should be encouraged to reach out to their healthcare providers if they have any questions or concerns about their medication. This ensures they have the support they need to manage their medication safely.
Choice D rationale
Providing the patient with written instructions only is not sufficient. While written instructions are helpful, they should be supplemented with verbal education and a demonstration if necessary. This ensures the patient fully understands how to take their medication and can ask questions if needed.
Correct Answer is A
Explanation
Choice A rationale
A client who has dysphagia should be seen first because dysphagia can lead to serious complications such as aspiration, choking, and pneumonia. Immediate assessment and intervention are necessary to ensure the client’s airway is protected and to prevent potential respiratory distress.
Choice B rationale
A client who asks about community resources is important, but this is not an urgent need. This client can be seen after addressing more immediate clinical concerns.
Choice C rationale
A client who will require oxygen at home needs proper planning and education, but this can be addressed after ensuring the immediate safety of clients with urgent needs.
Choice D rationale
A client who wants a priest to visit while they are in the hospital is a valid request, but it is not an urgent clinical need. This can be arranged after addressing clients with more immediate health concerns.
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