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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.

Prescribed medication

B.

Blood pressure readings

C.

Gait

D.

Reports of home environment

E.

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.


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Related Questions

Correct Answer is ["2.5"]

Explanation

Calculation:

Desired dose = 20 mg.

Available concentration = 40 mg / 5 mL

= 8 mg/mL.

  • Calculate the volume to administer in milliliters (mL).

Volume to administer (mL) = Desired dose (mg) / Available concentration (mg/mL)

= 20 mg / 8 mg/mL

= 2.5 mL.

Correct Answer is B

Explanation

Rationale:

A. Dietitian: A dietitian focuses on nutritional needs, which may be beneficial if the client has dietary concerns, but this does not directly address mobility issues related to lower extremity weakness.

B. Physical therapy: Physical therapists specialize in improving strength, balance, and mobility. A referral will help the client develop exercises and strategies to enhance function and reduce fall risk.

C. Case manager: A case manager coordinates healthcare services, but they do not directly provide rehabilitation for weakness. They may be involved later to arrange additional resources after therapy needs are determined.

D. Social services: Social services assist with psychosocial needs, financial support, and community resources, but they are not the primary referral for addressing physical mobility limitations.

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