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 D
Explanation
A. Showing the client how to use an artificial larynx is an important aspect of post-laryngectomy care, but determining the client's reading ability takes precedence as it will significantly impact communication options.
B. Arranging a support session is important for emotional support, but assessing the client's reading ability is more immediate in addressing communication needs.
C. Demonstrating the use of esophageal speech is relevant, but understanding the client's reading ability is a priority before exploring communication alternatives.
Correct Answer is ["B","C","D","E"]
Explanation
A. Eye exams are generally recommended more frequently, especially for older adults, to monitor for age-related changes and conditions.
B. Women should have a clinical breast examination every year, in addition to mammograms as recommended by their healthcare provider.
C. Both men and women should have a colonoscopy periodically, depending on individual risk factors and age.
D. Regular hearing screenings are important for older adults, especially as age-related hearing loss may occur.
E. Testicular self-exams are recommended for men to detect any abnormalities early on.
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