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 B
Explanation
A. Ciprofloxacin 200 mg IV q12h x 7 days is a clear and acceptable prescription.
B. "Dx" is an unaccepted abbreviation; it is not appropriate for documentation and may lead to confusion.
C. "Hourly 180" is unclear and may need clarification; it could refer to an hourly measurement or a specific order, but it lacks clarity.
D. Acetaminophen 1000 mg PO QD is a clear and acceptable prescription.
Correct Answer is B
Explanation
A. The frequency of previous vital sign measurements may be important but is not the most critical information to communicate during a transfer.
B. The effectiveness of the last dose of pain medication is crucial information for the receiving facility to manage the client's pain appropriately.
C. The number of family members who have visited is important for emotional support but may not be the priority for the receiving facility.
D. The time of the client's last bath is relevant but may not be as critical as information related to pain management during the hand-off report.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.