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 D
Explanation
Choice A reason: Low-Grade Fever
Low-grade fever is a common early symptom of rheumatoid arthritis (RA). It is often associated with the body’s inflammatory response to the autoimmune activity occurring in the joints. While it can persist throughout the disease, it is not considered a late manifestation.
Choice B reason: Weight Loss
Weight loss can occur in RA due to chronic inflammation and its effects on metabolism and appetite. However, it is more commonly seen in the early to middle stages of the disease rather than as a late manifestation. Persistent inflammation can lead to muscle wasting and weight loss, but these are not specific to the advanced stages of RA.
Choice C reason: Anorexia
Anorexia, or loss of appetite, is another symptom that can be present in RA. It is often related to the chronic inflammation and pain associated with the disease, which can reduce a person’s desire to eat. Like weight loss, anorexia can occur at various stages of RA and is not specifically a late manifestation.
Choice D reason: Knuckle Deformity
Knuckle deformity is a late manifestation of rheumatoid arthritis. As RA progresses, the chronic inflammation can lead to joint damage and deformities, particularly in the hands and fingers. This includes changes such as ulnar deviation, swan neck deformities, and boutonnière deformities. These deformities result from the destruction of joint tissues and the formation of scar tissue, which can significantly impair hand function.
Correct Answer is C
Explanation
Choice A reason: Dried fruits
Dried fruits are generally high in fiber, which can be problematic for individuals with a colostomy, especially in the initial weeks following surgery. High-fiber foods can increase stool bulk and may cause blockages or discomfort. It is recommended to avoid high-fiber foods until the digestive system has adjusted and the healthcare provider gives the go-ahead to reintroduce them gradually.
Choice B reason: Dried peas
Dried peas, like other legumes, are also high in fiber and can cause gas and bloating. These symptoms can be particularly uncomfortable for individuals with a colostomy. Additionally, legumes can increase the risk of blockages in the stoma. Therefore, it is advisable to avoid dried peas and other high-fiber legumes until the digestive system has fully adjusted.
Choice C reason: Eggs
Eggs are an excellent food choice for individuals with a colostomy. They are high in protein, which is essential for wound healing and overall recovery. Eggs are also easy to digest and do not typically cause gas or bloating. Including eggs in the diet can help ensure that the client receives adequate nutrition without causing digestive discomfort.
Choice D reason: Pasta
Pasta, particularly refined pasta, is generally low in fiber and easy to digest, making it a suitable food choice for individuals with a colostomy. It provides a good source of carbohydrates, which are important for energy. However, it is essential to monitor portion sizes and avoid adding high-fat or high-fiber ingredients that could cause digestive issues.
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