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 D
Explanation
Choice A rationale
Fatigue is a subjective symptom reported by the client. It is based on the client’s personal experience and cannot be objectively measured or observed by the nurse. Therefore, it is not considered objective data.
Choice B rationale
Dizziness is also a subjective symptom reported by the client. It reflects the client’s personal experience and cannot be directly observed or measured by the nurse. As such, it is not considered objective data.
Choice C rationale
Numbness is another subjective symptom reported by the client. It is based on the client’s personal sensation and cannot be objectively measured or observed by the nurse. Therefore, it is not considered objective data.
Choice D rationale
Physical examination results are objective data. They are obtained through direct observation, measurement, and assessment by the nurse. Examples of objective data include vital signs, physical examination findings, and laboratory results. These data are reproducible and can be verified by other healthcare professionals.
Correct Answer is C
Explanation
Choice A rationale
Avoiding eye contact to prevent confusion is incorrect. Eye contact is an important aspect of effective communication and helps to establish a connection with the client. Avoiding eye contact can make the client feel ignored or unimportant, which can hinder understanding and trust.
Choice B rationale
Speaking quickly to maintain the client’s attention is incorrect. Clients with cognitive impairment may have difficulty processing information quickly. Speaking slowly and clearly allows the client more time to understand and respond to the information being communicated.
Choice C rationale
Allowing the client extra time to respond is correct. Clients with cognitive impairment may need additional time to process information and formulate a response. Allowing extra time helps to ensure that the client fully understands the information and can respond appropriately.
Choice D rationale
Using complex sentences to stimulate cognitive function is incorrect. Simple and clear communication is more effective for clients with cognitive impairment. Complex sentences can be confusing and difficult for the client to understand, which can hinder effective communication.
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