A nurse in a provider's office is caring for a client.
Prescribed medication
Blood pressure readings
Gait
Reports of home environment
Voiding pattern
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Teach the client relaxation techniques: Teaching coping strategies is helpful but does not address the immediate need to understand the client’s perception of the crisis. It should follow assessment.
B. Confirm the client's perception of the event: The first step in crisis intervention is to assess and understand the client’s view of the situation. Clarifying perception allows the nurse to accurately prioritize interventions and provide appropriate support.
C. Notify the client's support person: Contacting support is beneficial for ongoing assistance but should occur after assessing the client’s understanding and emotional state.
D. Help the client identify personal strengths: Identifying strengths promotes coping and resilience, but it is a secondary intervention that should follow assessment and clarification of the client’s perception.
Correct Answer is C
Explanation
Rationale:
A. Ensure that each client has a living will on file prior to treatment: While advance directives are encouraged, clients have the right to choose whether to have one, and care cannot be delayed or denied if they do not.
B. Place copies of incident reports in clients' medical records: Incident reports are internal risk management tools and should not be placed in the medical record, as this could increase legal liability and compromise confidentiality.
C. Obtain personal professional liability insurance coverage: Having individual liability coverage provides additional protection beyond employer coverage, ensuring legal and financial support if malpractice claims arise.
D. Overestimate clients' acuity to prevent short staffing: Falsifying acuity levels is unethical and can result in disciplinary action or loss of license; staffing concerns should be addressed through proper administrative channels.
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