A nurse is caring for four clients. Which of the following clients is at the greatest risk for falling?
A client who has diminished vision ambulating in well-lit areas
A client who received a diuretic 30 min ago
A client who requires assistance with ambulation
A client who had a tonic-clonic seizure 2 hr ago
The Correct Answer is D
A. A client with diminished vision ambulating in well-lit areas may be at risk for falling but is not at the greatest risk among the options provided.
B. A client who received a diuretic 30 min ago may experience orthostatic hypotension, which can increase the risk of falling, but it is not the highest risk.
C. A client who requires assistance with ambulation is generally at a lower risk than a client who has recently experienced a tonic-clonic seizure.
D. A client who had a tonic-clonic seizure 2 hr ago is at the greatest risk for falling due to potential residual weakness, disorientation, or postictal state following the seizure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Having the guard sign a release of information form may not be appropriate in an emergency situation, and immediate action is needed to address the injury.
B. Telling the guard to submit an inmate inquiry form to the warden may delay necessary medical intervention in an emergency.
C. Completing an incident report is appropriate to document the situation and the care provided It is not necessary to disclose the inmate's HIV status in the report.
D. Instructing the guard to ask the inmate is not a proper approach to handling a medical emergency. The nurse should focus on providing immediate care to the injured inmate.
Correct Answer is B
Explanation
A. Expressing a desire to understand why the amputation happened suggests the client is still grappling with acceptance.
B. Expressing discomfort with therapy but being comfortable with the prosthesis indicates an acknowledgment of the loss and adaptation to the situation.
C. Noting the leg's appearance and healing is an observation but does not necessarily indicate acceptance.
D. Indicating a readiness to talk about the leg in a week or so suggests the client is not currently ready to discuss or fully accept the loss.
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