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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Encouraging the use of sedatives to promote better sleep is incorrect. Sedatives can increase the risk of falls in older adults due to their side effects, such as dizziness and impaired coordination. It is important to use non-pharmacological methods to promote sleep and reduce fall risk.
Choice B rationale
Removing tripping hazards from the home is a key action to reduce falls in older adults. This includes securing loose rugs, keeping walkways clear, and ensuring that cords and other objects are not in areas where they could cause a trip. By creating a safer environment, the risk of falls is significantly reduced.
Choice C rationale
Ensuring proper lighting in all areas of the home is also important for fall prevention. Adequate lighting helps older adults see potential hazards and navigate their environment safely. This includes using nightlights in hallways and bathrooms and ensuring that all rooms are well-lit.
Choice D rationale
Avoiding the use of diuretics at night can help reduce the need for nighttime bathroom trips, which can be a fall risk. However, this choice alone is not as comprehensive as removing tripping hazards, which addresses multiple potential fall risks in the home.
Correct Answer is ["B","C","D"]
Explanation
The correct answers are Choices B, C, and D.
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