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 {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"}}

Explanation

Lack of sleep: Decreased need for sleep is a core feature of mania, where individuals may go days with minimal rest and still appear energetic or overly active. It is not a defining feature of psychosis, though it may occur secondarily.
Pressured speech: Pressured, rapid, and difficult-to-interrupt speech is strongly associated with mania, reflecting accelerated thought processes and elevated mood. It is uncommon in psychosis unless mania and psychotic features coexist.
Disorganized thought process: This is a hallmark of psychosis, often seen in disorders like schizophrenia. It includes loose associations, tangentiality, and difficulty organizing ideas, and can impair communication significantly.
Excessive spending habits: Engaging in impulsive or risky financial behaviors is a classic symptom of mania, often driven by grandiosity or impaired judgment. This behavior is not typical of psychosis unless mania is also present.
Hallucinations: Perceptual disturbances such as seeing or hearing things that are not present are definitive features of psychosis. While they can occur in severe mania with psychotic features, they are primarily linked to psychotic disorders.

A. Place the tip of the thermometer under the center of the infant's axilla B. Pull the pinna of the Infant's ear forward before inserting the probe. C. Insert the oral thermometer in front of the infant's tongue. D. Insert the probe 3.8 cm (15 in into the infant's rectum

Correct Answer is A

Explanation

A. Place the tip of the thermometer under the center of the infant's axilla: This is the correct method for taking an axillary temperature in infants, which is the recommended route due to safety and ease. The tip should be placed snugly in the center of the axilla and the infant's arm should be held firmly against their body to ensure accuracy.
B. Pull the pinna of the infant's ear forward before inserting the probe: This technique is used for otoscopic or tympanic temperature readings in children under 3, but tympanic readings are not preferred in young infants due to the small size and curvature of their ear canals, which can lead to inaccuracy.
C. Insert the oral thermometer in front of the infant's tongue: Oral temperature measurement is inappropriate for infants. They may not be able to keep the thermometer properly positioned, which increases the risk of inaccurate readings or injury.
D. Insert the probe 3.8 cm (1.5 in) into the infant's rectum: Rectal temperature measurement is not routinely recommended unless specifically indicated, and the probe should only be inserted about 1.3 cm (0.5 in) for infants to avoid rectal perforation. The option listed suggests unsafe depth.

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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?

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Naxlex Comprehensive Predictor Exams

The nurse continues to care for the client. Exhibits For each assessment finding, click to specify if the finding is consistent with psychosis or mania. Each finding may support more than one diagnosis.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"}}

Explanation

A nurse is preparing to measure the temperature of an infant. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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