Try Naxlex NCLEX-RN (Free-Trial)

A nurse in a provider's office is caring for a client.

Exhibits
The nurse is performing a fall risk assessment for the client. Select the 3 findings that place the client at risk for a fall.

Prescribed medication

Blood pressure readings

Gait

Reports of home environment

Voiding pattern

Answer and Explanation

Correct Answer : A,B,E

Rationale for correct choices:

Prescribed medication: The client is taking hydrochlorothiazide, a diuretic that can cause dizziness, orthostatic hypotension, and increased nighttime urination. These side effects increase the risk for falls, especially in older adults who may already have mobility limitations.
Blood pressure readings: The client’s blood pressure dropped from sitting 138/84 mm Hg to standing 100/70 mm Hg, indicating orthostatic hypotension. This sudden decrease in blood pressure can cause lightheadedness, dizziness, or fainting, all of which increase the likelihood of falls.
Voiding pattern: The client reports waking 2–3 times per night to void. Nocturia increases fall risk because the client must get up in low-light conditions, potentially while drowsy, making them more susceptible to tripping or losing balance.

Rationale for incorrect choices:

Gait: The client’s gait is steady, and no abnormalities were noted during assessment. While gait disturbances can increase fall risk, in this case, the client’s mobility does not currently contribute to risk.
Reports of home environment: The client has already removed throw rugs and increased lighting, implementing effective fall prevention strategies at home. Therefore, the home environment does not currently place the client at increased risk for falls.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is ["B","D","E"]

Explanation

A. Refute the client's delusions using logic: Confronting or trying to correct delusions can increase agitation and confusion in clients with dementia. This approach is not therapeutic and should be avoided.

B. Give the client one simple direction at a time: Providing clear, single-step instructions reduces confusion and helps the client successfully complete tasks, supporting independence and minimizing frustration.

C. Allow the client to choose among a variety of activities each day: Offering too many choices can overwhelm a client with dementia, leading to anxiety and agitation. It is more effective to offer a simple choice between two options or to provide a structured routine to reduce decision fatigue.

D. Establish eye contact when communicating with the client: Eye contact enhances attention, conveys respect, and improves comprehension during interactions, which is particularly important for clients with cognitive impairment.

E. Reinforce orientation to time, place, and person: Gentle reminders and reorientation cues help maintain cognitive function, reduce anxiety, and support the client’s awareness of their environment.

A. Expected outcome of the procedure B. Potential complications C. Cost of the procedure D. Explanation of the procedure E. Possible alternative treatments

Correct Answer is ["A","B","D","E"]

Explanation

A. Expected outcome of the procedure: The provider must explain the anticipated results of the colon resection so the client can make an informed decision about proceeding with the surgery.

B. Potential complications: The client should be informed of the risks and possible adverse events associated with the procedure, which is essential for informed consent.

C. Cost of the procedure: Financial information is not required for informed consent. While helpful for planning, it is not part of the medical disclosure required by the provider.

D. Explanation of the procedure: A clear description of the surgical steps allows the client to understand what the procedure entails, which is a fundamental component of informed consent.

E. Possible alternative treatments: The client must be aware of other treatment options, including the choice of no treatment, to make an informed decision regarding surgery.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse in a provider's office is caring for a client. Exhibits The nurse is performing a fall risk assessment for the client. Select the 3 findings that place the client at risk for a fall.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for an older adult client who has dementia. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.)

Correct Answer is ["B","D","E"]

Explanation

A nurse is preparing to witness a client's signature on a consent form for a colon resection. The nurse should recognize that which of the follow information should be provided to the client by the provider before signing the form? (Select all that apply.)

Correct Answer is ["A","B","D","E"]

Explanation

The nurse reviews the entries in the medical record. Exhibits The nurse is ready to begin the blood transfusion. For each potential nursing action, click to specify if the action is indicated or not indicated for the client

A nurse is caring for a client who is postoperative immediately following a cardiac catheterization with a right femoral approach. Which of the following actions should the nurse take?

A nurse is caring for a female client who requests a contraceptive diaphragm. Which of the following actions should the nurse take first?

A nurse in a provider's office is caring for a client. Exhibits The nurse is performing a fall risk assessment for the client. Select the 3 findings that place the client at risk for a fall.

A nurse is caring for a client who has preeclampsia and is receiving magnesium sulfate. The client reports that she is experiencing difficulty breathing. Which of the following actions should the nurse take first?

A nurse on a pediatric unit is preparing to insert an IV catheter for a 7-year-old child who is dehydrated. Which of the following actions should the nurse take?

A nurse on a medical-surgical unit is caring for a client who states that she plans to leave the facility against medical advice. For which of the following actions by the nurse should the charge nurse intervene?

A nurse is implementing seizure precautions for a client who has had a tonic-clonic seizure. Which of the following interventions should the nurse include in the plan of care?

A nurse in a provider's office is caring for a client.

Exhibits
The nurse is performing a fall risk assessment for the client. Select the 3 findings that place the client at risk for a fall.