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 ["A","B","C","D"]
Explanation
A) Bright light: Exposure to bright light, especially in the evening or at night, can interfere with the body's production of melatonin, a hormone that regulates the sleep-wake cycle. Bright light exposure can disrupt circadian rhythms, making it more challenging to fall asleep and stay asleep.
B) Drinking caffeinated beverages in the evening: Caffeine is a stimulant that can interfere with sleep by blocking the effects of adenosine, a neurotransmitter that promotes sleepiness. Consuming caffeinated beverages in the evening can delay the onset of sleep and reduce overall sleep duration.
C) A 20-minute nap during the day: While short naps can be beneficial for some individuals, especially if they are sleep-deprived, napping for too long or too late in the day can disrupt the body's natural sleep-wake cycle. Short naps can be refreshing, but longer or late-day naps can make it harder to fall asleep at night.
D) Emotional stress: Stress and anxiety can trigger the body's "fight or flight" response, leading to increased alertness and difficulty relaxing or falling asleep. Chronic stress can disrupt the sleep-wake cycle, leading to difficulty initiating or maintaining sleep and resulting in poor sleep quality.
E) A regular bedtime schedule: Having a consistent bedtime schedule can actually help regulate the sleep-wake cycle by reinforcing the body's internal clock. Going to bed and waking up at the same time each day, even on weekends, can help improve sleep quality and make it easier to fall asleep and wake up naturally.
Correct Answer is C
Explanation
A) Gelatin: Gelatin is a suitable choice for a clear liquid diet. It is transparent and easily digestible, making it appropriate for individuals requiring clear liquids, such as those recovering from certain medical procedures or surgeries.
B) Popsicle: Popsicles are commonly included in clear liquid diets. They provide hydration and can help soothe a sore throat or provide relief from nausea. However, it is essential to ensure that the popsicle is clear and does not contain any solid fruit or pieces.
C) Yogurt: Yogurt is not typically included in a clear liquid diet. Clear liquid diets consist of transparent or translucent fluids that are easily digested and leave minimal residue in the gastrointestinal tract. Yogurt, being a semi-solid food, contains particles that are not clear and is typically considered a full liquid or soft diet item rather than a clear liquid. Therefore, the client's choice of yogurt indicates a need for further teaching regarding appropriate food choices for a clear liquid diet.
D) Broth: Broth, such as chicken or beef broth, is a staple of clear liquid diets. It is easily digested and provides essential electrolytes and hydration. Broth can be consumed hot or cold, depending on the client's preference and medical condition.
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