A nurse is conducting a fall risk assessment for a patient.
Which of the following factors would increase the patient’s risk of falling?
The presence of a grab bar in the bathroom.
An electrical cord lying across a walkway.
The patient has macular degeneration.
There are throw rugs in the kitchen.
The patient uses a cane to ambulate.
Correct Answer : B,C,D,E
Choice A rationale
The presence of a grab bar in the bathroom is actually a safety measure that can help prevent falls. It provides support for the patient when they are getting up or moving around, reducing the risk of a fall.
Choice B rationale
An electrical cord lying across a walkway is a tripping hazard and would increase the patient’s risk of falling. It is important to keep walkways clear of clutter and potential obstacles to prevent falls.
Choice C rationale
Macular degeneration can affect the patient’s vision, making it difficult for them to see obstacles or changes in the walking surface. This can increase their risk of falling.
Choice D rationale
Throw rugs in the kitchen can easily slip or bunch up, creating a tripping hazard. They should be secured with non-slip backing or removed to reduce the risk of falls.
Choice E rationale
While a cane can provide support and improve balance, it also indicates that the patient has mobility issues, which increases their risk of falling. It is important that the patient uses the cane correctly and that it is the right height for them.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is AANDD
Explanation
Choice A rationale
An ileostomy involves creating a stoma, or opening, in the abdominal wall. The location of the stoma is typically in the right lower abdomen.
Choice B rationale
The end of the stoma should not be painful after the procedure. If the patient experiences pain, it could indicate a complication and should be reported to the healthcare provider.
Choice C rationale
The patient should not expect the stoma to be a purple color. A healthy stoma should be red or pink. A purple stoma could indicate a lack of blood flow, which is a serious issue that needs immediate medical attention.
Choice D rationale
After an ileostomy, the patient will have liquid or semi-liquid stool pass through the stoma. This is because the large intestine, which normally absorbs water and forms solid stool, is bypassed or removed in the procedure.
Correct Answer is ["A","C"]
Explanation
Choice A rationale
A specific gravity of 1.036 is higher than the normal range of 1.005 to 1.030345. This could indicate dehydration or other conditions that cause the urine to be more concentrated. This finding should prompt the nurse to follow up.
Choice B rationale
A pH of 6.4 is within the normal range for urine, which is typically between 4.6 and 8.03. Therefore, this finding would not necessarily require follow-up.
Choice C rationale
The presence of proteinuria (protein in the urine) is abnormal and could indicate kidney disease or other serious health conditions. This finding should prompt the nurse to follow up.
Choice D rationale
The presence of hematuria (blood in the urine) can be a sign of several conditions, including urinary tract infections, kidney stones, or bladder infections. However, without more information, it’s not clear whether this finding alone should prompt the nurse to follow up.
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