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 A
Explanation
Choice A rationale
A black pressure ulcer indicates necrotic tissue, which often requires surgical debridement.
Choice B rationale
Increased drainage from the wound is not typically associated with a black pressure ulcer.
Choice C rationale
While documenting the wound status daily is part of wound care, it is not a specific event anticipated when planning care for a patient with a black pressure ulcer.
Choice D rationale
Increased monitoring of the wound condition is part of wound care, but it is not a specific event anticipated when planning care for a patient with a black pressure ulcer.
Correct Answer is ["B","C","D"]
Explanation
Choice A rationale
Using soap to clean the patient’s skin is not the best practice. Soap can dry out and irritate the skin, especially in patients with urinary incontinence. It can disrupt the skin’s natural pH balance and make it more susceptible to damage.
Choice B rationale
Applying a barrier cream to the patient’s skin is a recommended practice. Barrier creams provide a protective layer on the skin that can help prevent irritation from urine. They can also help to keep the skin moisturized, which is important for maintaining skin integrity.
Choice C rationale
Avoiding friction when drying the patient’s skin is crucial. Friction can cause further damage to the skin, especially in areas that are already irritated or broken down due to incontinence. It’s recommended to gently pat the skin dry rather than rubbing it.
Choice D rationale
Using warm water to clean the patient’s skin is a good practice. Warm water is less irritating to the skin than hot water and can help to cleanse the area without causing additional discomfort or damage.
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