A nurse is collecting data from a client who has an acute condition. Which of the following findings should the nurse identify as increasing the risk for potential client injuries?
Hearing acuity intact
Oriented to person only
Full range of motion bilateral lower extremities
Ability to use call light
The Correct Answer is B
A) Hearing acuity intact - Intact hearing acuity does not directly increase the risk for potential client injuries.
B) Oriented to person only - Being oriented to person only may indicate confusion or disorientation, which can increase the risk for potential client injuries due to impaired decision-making or awareness of surroundings.
C) Full range of motion bilateral lower extremities - Having a full range of motion in the lower extremities does not directly increase the risk for potential client injuries.
D) Ability to use call light - The ability to use a call light indicates the client's ability to seek assistance, which reduces the risk for potential client injuries.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. History of dementia- Dementia can impair cognitive function and increase the risk of accidents or injuries, such as falls or wandering.
B. Steady gait- A steady gait indicates good balance and is not typically considered a risk factor for accidents or injuries.
C. History of gastric reflux- Gastric reflux may cause discomfort but is not directly related to an increased risk of accidents or injuries.
D. Age of 45- While age can be a risk factor for certain conditions, such as falls in older adults, being 45 years old alone does not necessarily indicate an increased risk of accidents or injuries.
Correct Answer is C
Explanation
A) Tuna fish - Tuna fish is a source of animal protein and is not suitable for a lacto- vegetarian diet, which excludes meat but includes dairy.
B) Clam chowder - Clam chowder typically contains seafood and is not suitable for a lacto-vegetarian diet.
C) Cheese - Cheese is a dairy product and is suitable for a lacto-vegetarian diet, which includes dairy but excludes meat.
D) Chicken - Chicken is a source of animal protein and is not suitable for a lacto- vegetarian diet.
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