A nurse is assessing a client to determine their fall risk. Which of the following findings should alert the nurse that the client is at risk for falls?

1+ pedal edema

Bruises on the lower extremities

Impaired vision

Coarse rhonchi auscultated over the trachea

Answer and Explanation

The Correct Answer is C

A. 1+ pedal edema. Mild pedal edema is typically not associated with instability or falls, unless it progresses to severe swelling that affects mobility or balance. It is a sign of fluid retention but not a direct fall risk indicator on its own.
B. Bruises on the lower extremities. Bruising can be a sign of previous falls or trauma, but it is not itself a cause or indicator of fall risk. While it may prompt further investigation, it does not confirm fall risk independently.
C. Impaired vision. Visual impairment is a significant risk factor for falls because it affects depth perception, ability to detect hazards, and overall spatial awareness. Clients with impaired vision are more likely to trip, misjudge steps, or bump into obstacles.
D. Coarse rhonchi auscultated over the trachea. Coarse rhonchi are respiratory findings typically related to mucus in the airways and do not directly contribute to fall risk unless accompanied by severe respiratory distress or fatigue.

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Correct Answer is C

Explanation

A. Ketorolac. This is a nonsteroidal anti-inflammatory drug (NSAID) that can increase the risk of gastrointestinal bleeding, especially in clients with a history of peptic ulcer disease. It should be avoided in this population.
B. Aspirin. Aspirin is also an NSAID and can irritate the gastric lining, increasing the risk of ulceration and bleeding. It is contraindicated in clients with peptic ulcers.
C. Acetaminophen. Acetaminophen is the safest option for clients with peptic ulcer disease because it does not affect the gastric mucosa. It provides effective relief for mild to moderate pain, including headaches.
D. Ibuprofen. Like ketorolac and aspirin, ibuprofen is an NSAID and is not recommended for clients with peptic ulcers due to the increased risk of gastrointestinal irritation and bleeding.

A. Encourage a passive communication style. B. Publicly confront coworkers when conflict arises. C. Establish a strong employee code of conduct D. Focus on self-care

Correct Answer is D

Explanation

A. Encourage a passive communication style. Passive communication can lead to unresolved stress and burnout, as it prevents individuals from expressing their needs or concerns effectively. It is not a recommended strategy for managing compassion fatigue.
B. Publicly confront coworkers when conflict arises. Public confrontation can escalate tension and create a hostile work environment, which contributes to stress rather than alleviating it. Conflict should be addressed professionally and privately.
C. Establish a strong employee code of conduct. While a code of conduct is important for maintaining professional behavior, it does not directly address the emotional toll of compassion fatigue or promote personal well-being among staff.
D. Focus on self-care. Self-care is essential in preventing and managing compassion fatigue, which results from the emotional demands of caring for others. Encouraging activities that promote emotional, physical, and mental well-being helps staff maintain resilience and avoid burnout.

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A nurse is assessing a client to determine their fall risk. Which of the following findings should alert the nurse that the client is at risk for falls?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who reports a headache and has a history of a peptic ulcer. Which of the following medications should the nurse administer?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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