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 ["15"]
Explanation
Step 1: Determine the dosage available per mL.
- The available dosage is 75 mg per 5 mL.
- To find the dosage per mL, divide 75 mg by 5 mL.
- 75 mg ÷ 5 mL = 15 mg/mL.
- Result: 15 mg/mL.
Step 2: Determine how many mL are needed for the prescribed dose.
- The prescribed dose is 225 mg.
- To find the required mL, divide 225 mg by the dosage per mL (15 mg/mL).
- 225 mg ÷ 15 mg/mL = 15 mL.
- Result: 15 mL.
So, the nurse should administer 15 mL of clindamycin palmitate oral suspension every 8 hours.
Correct Answer is ["B","D","E"]
Explanation
Choice A: Wash raw carrots before cooking
Reason: Washing raw vegetables, including carrots, before cooking is essential to remove dirt, bacteria, and pesticide residues. However, this option is not specific to preventing foodborne illnesses. Washing vegetables is a general hygiene practice, but it does not address the broader aspects of food safety, such as preventing cross-contamination or ensuring proper cooking temperatures. Therefore, while important, it is not the most critical instruction for preventing foodborne illnesses in this context.
Choice B: Separate raw foods from ready-to-eat foods
Reason: Separating raw foods from ready-to-eat foods is crucial to prevent cross-contamination. Raw foods, especially meats, poultry, and seafood, can harbor harmful bacteria that can transfer to ready-to-eat foods if not kept separate. This separation should be maintained during storage, preparation, and cooking. For example, raw meat should be stored on the bottom shelf of the refrigerator to prevent juices from dripping onto other foods. Using separate cutting boards and utensils for raw and ready-to-eat foods further minimizes the risk of cross-contamination.
Choice C: Wash utensils with warm water
Reason: While washing utensils with warm water is a good practice, it is not sufficient on its own to ensure food safety. Utensils that have come into contact with raw meat, poultry, or seafood should be washed with hot, soapy water and sanitized to kill any harmful bacteria. Simply using warm water may not effectively remove or kill bacteria, making this option less critical compared to others that directly address foodborne illness prevention.
Choice D: Practice good hand washing after handling raw eggs, meat, or poultry
Reason: Practicing good hand washing after handling raw eggs, meat, or poultry is one of the most effective ways to prevent foodborne illnesses. Hands can easily transfer bacteria from raw foods to other surfaces, utensils, and foods. Proper hand washing involves scrubbing hands with soap and water for at least 20 seconds, ensuring all parts of the hands are cleaned. This practice helps to eliminate harmful bacteria and reduce the risk of cross-contamination.
Choice E: Ensure all food is cooked to 165°F. Promptly refrigerate foods when finished eating
Reason: Cooking food to the proper internal temperature is essential to kill harmful bacteria that can cause foodborne illnesses. For most foods, an internal temperature of 165°F (73.9°C) is recommended to ensure safety. Using a food thermometer to check the temperature is the best way to ensure food is cooked thoroughly. Additionally, promptly refrigerating foods after eating helps to prevent bacterial growth. Bacteria can multiply rapidly at room temperature, so refrigerating leftovers within two hours (or one hour if the temperature is above 90°F) is crucial for food safety.
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