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
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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Related Questions
Correct Answer is C
Explanation
A. Widening pulse pressure. This is typically associated with conditions like increased intracranial pressure or severe aortic regurgitation, not cardiac tamponade. Tamponade usually results in narrowed pulse pressure.
B. Coarse lung sounds. These may indicate fluid overload or pulmonary congestion, but they are not specific to cardiac tamponade and occur later or in different conditions.
C. Muffled heart sounds. This is a classic early sign of cardiac tamponade, caused by fluid accumulation in the pericardial sac, which dampens heart sounds on auscultation. It is part of Beck’s triad (muffled heart sounds, hypotension, and jugular vein distention).
D. Decreased jugular vein distention. In cardiac tamponade, jugular vein distention increases due to impaired venous return to the heart. Decreased JVD would be an unexpected finding in this condition.
Correct Answer is C
Explanation
A. "How long have you struggled with your weight?" While this may provide background information, it shifts the focus to the client's weight history rather than validating their current emotional experience and distress.
B. "Let's discuss some weight loss strategies that might work for you." This response prematurely shifts to problem-solving and weight management without first addressing the client’s emotional needs or acknowledging their feelings of embarrassment and vulnerability.
C. "It sounds like you're saying that you feel uncomfortable around others." This is a therapeutic, reflective response that validates the client’s feelings and encourages them to express more about their emotional experience, fostering trust and emotional support.
D. "Have you always felt uncomfortable being overweight?" This question may come across as judgmental and focuses too much on the client's body image history rather than their current emotional experience, potentially worsening feelings of shame.
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