A nurse is conducting a fall risk assessment for her clients. The nurse should identify that which of the following clients is the greatest risk for a fall?
An older adult who is confused and has urinary frequency
An older adult with hearing impairment
A client who has a dressing on his foot due to a pressure ulcer
A client who has osteoarthritis and uses a walker
The Correct Answer is A
A) An older adult who is confused and has urinary frequency:
This client is at the greatest risk for a fall due to several factors. Confusion increases the likelihood of disorientation and impaired judgment, leading to accidents. Urinary frequency may necessitate frequent trips to the bathroom, increasing the chances of falls, especially if the client is disoriented or unsteady on their feet.
B) An older adult with hearing impairment:
While hearing impairment can contribute to a fall risk by limiting the client's ability to hear warnings or instructions, it may not pose as immediate a risk as confusion and urinary frequency, which directly affect mobility and judgment.
C) A client who has a dressing on his foot due to a pressure ulcer:
While having a dressing on the foot due to a pressure ulcer increases the risk of falls by potentially affecting the client's gait and balance, it may not be as significant a risk factor as confusion and urinary frequency, which directly impact the client's ability to safely navigate their environment.
D) A client who has osteoarthritis and uses a walker:
Although osteoarthritis and the use of a walker can contribute to mobility issues and an increased risk of falls, they may not present as immediate a risk as confusion and urinary frequency, which can lead to more unpredictable and hazardous situations.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) The client tolerates a second dose of medication with no greater than 1 peripheral edema:
This does not directly indicate a therapeutic response to epinephrine for angioedema. Angioedema primarily involves swelling of deeper layers of the skin, often around the eyes and lips, and sometimes the throat, which can cause breathing difficulties. Tolerating a second dose of medication with minimal peripheral edema does not specifically address the acute respiratory effects of angioedema.
B) Respirations are unlabored:
This is the correct answer. Angioedema can cause swelling in the airways, leading to difficulty breathing. Epinephrine is used to reduce this swelling and improve airway patency. Unlabored respirations indicate that the airway is not obstructed, which means the epinephrine has successfully alleviated the swelling causing the angioedema.
C) Client reports decreased groin pain of 3 on a 1 to 10 scale:
Decreased groin pain is not relevant to the treatment of angioedema with epinephrine. Pain relief in the groin area does not indicate a therapeutic response to epinephrine, which is primarily used to address airway and anaphylactic symptoms.
D) The client's blood pressure when arising from resting position is at premedication levels:
While epinephrine can affect blood pressure, the main concern with angioedema is airway obstruction rather than blood pressure control. Normalizing blood pressure does not specifically indicate that the epinephrine has successfully treated the angioedema and improved the client's respiratory status.
Correct Answer is A
Explanation
A. Lavender:
Lavender essential oil is well-known for its calming and relaxing properties. It is often used to promote sleep and alleviate insomnia symptoms. Research suggests that inhaling lavender aroma or using lavender oil in aromatherapy can help improve sleep quality by reducing anxiety and promoting relaxation.
B. Orange:
While orange essential oil has a refreshing and uplifting scent, it is not typically used to promote sleep. Instead, it is often used to boost mood and energy levels due to its citrusy aroma.
C. Peppermint:
Peppermint essential oil has a stimulating and invigorating scent, making it more suitable for promoting alertness and mental clarity rather than inducing sleep. It is commonly used to alleviate fatigue and increase focus.
D. Ginger:
Ginger essential oil has a warm and spicy aroma that is often used for its energizing and revitalizing effects. Similar to peppermint, ginger is not typically used to promote sleep but may help alleviate fatigue and increase mental alertness.
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