A nurse is caring for a patient on a medical-surgical unit.
A nurse is performing a fall risk assessment on a patient. Which of the following findings indicate that the patient is at increased risk for falls? Select all that apply
WBC Count
Parkinson’s disease
Potassium level on day 2
Furosemide
Low blood pressure
Correct Answer : B,C,D,E
Choice A: WBC Count
Reason: The white blood cell (WBC) count is not directly related to fall risk. WBC count is an indicator of the immune system’s response to infection or inflammation. In this case, the patient’s WBC count is within the normal range (5,000 to 10,000/mm³) on both days. Therefore, it does not contribute to an increased risk of falls.
Choice B: Parkinson’s disease
Reason: Parkinson’s disease significantly increases the risk of falls due to several factors. Patients with Parkinson’s often experience postural instability, which is the inability to maintain balance when standing or walking. This condition is a cardinal feature of Parkinson’s disease and can lead to frequent falls. Additionally, Parkinson’s patients may experience freezing of gait, where they suddenly cannot move their feet forward despite the intention to walk. This can cause them to fall. Other gait abnormalities, such as festinating gait (short, rapid steps) and dyskinesias (involuntary movements), also contribute to the increased fall risk.
Choice C: Potassium level on day 2
Reason: The patient’s potassium level on day 2 is 3.0 mEq/L, which is below the normal range of 3.5 to 5 mEq/L. Low potassium levels (hypokalemia) can lead to muscle weakness, cramps, and fatigue. These symptoms can impair the patient’s ability to maintain balance and increase the risk of falls. Hypokalemia can also cause abnormal heart rhythms, which can further contribute to the risk of falls.
Choice D: Furosemide
Reason: Furosemide is a diuretic medication used to treat conditions such as heart failure by reducing fluid buildup in the body. However, it can also cause orthostatic hypotension, a condition where blood pressure drops significantly when standing up. This can lead to dizziness, lightheadedness, and an increased risk of falls. Additionally, furosemide can cause electrolyte imbalances, such as low potassium levels, which can further contribute to fall risk.
Choice E: Low blood pressure
Reason: The patient’s blood pressure readings indicate orthostatic hypotension, with a significant drop from 128/56 mm Hg while sitting to 92/40 mm Hg while standing. Orthostatic hypotension is a common condition in patients with Parkinson’s disease and heart failure. It can cause dizziness, lightheadedness, and fainting when changing positions, increasing the risk of falls. The patient’s low blood pressure when standing is a clear indicator of increased fall risk.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Inserting a nasogastric tube is not the first-line intervention for postoperative nausea and vomiting (PONV). This invasive procedure is typically reserved for severe cases where other interventions have failed.
Choice B reason:
Administering an antiemetic is the appropriate action. Antiemetics help control nausea and vomiting, which are common side effects of opioids like morphine. This intervention can provide immediate relief and improve the client’s comfort.
Choice C reason:
Auscultating bowel sounds is important for assessing gastrointestinal function, but it does not directly address the immediate symptom of nausea and vomiting. This assessment can be part of the overall evaluation but is not the primary intervention.
Choice D reason:
Encouraging the client to ambulate is beneficial for overall recovery and can help reduce the risk of complications such as deep vein thrombosis. However, it does not directly address the immediate issue of nausea and vomiting.
Correct Answer is A
Explanation
Choice A reason:
Obtaining a 12-lead ECG is crucial for a client with a potassium level of 6.8 mEq/L, which indicates hyperkalemia. Hyperkalemia can cause life-threatening cardiac dysrhythmias, and an ECG can help detect these abnormalities early.
Choice B reason:
Suggesting that the client use a salt substitute is not appropriate in this situation. Many salt substitutes contain potassium chloride, which can further increase potassium levels and exacerbate hyperkalemia.
Choice C reason:
Asking the client to add citrus juices and bananas to her diet is also inappropriate. These foods are high in potassium and can worsen hyperkalemia.
Choice D reason:
While obtaining a blood sample for a serum sodium level can be part of the overall assessment, it is not the immediate priority. The primary concern with hyperkalemia is the risk of cardiac dysrhythmias, which makes obtaining a 12-lead ECG the most urgent action.
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