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 D
Explanation
A) Palliative care is limited to clients who are in a healthcare facility: Palliative care can be provided in various settings, including hospitals, hospices, long-term care facilities, and even in the client's home. It is not limited to clients who are in a healthcare facility.
B) The goal of palliative care is to cure an acute illness for a client: Palliative care focuses on providing relief from the symptoms and stress of a serious illness, rather than curing the illness itself. The primary goal is to improve the quality of life for both the client and their family, focusing on physical, psychosocial, and spiritual aspects of care.
C) Palliative care is restricted to clients who are terminally ill: While palliative care is often associated with end-of-life care for clients with terminal illnesses, it is not limited to this population. Palliative care can be provided at any stage of a serious illness, from diagnosis through treatment, survivorship, or end-of-life care.
D) Palliative care can be provided to a client who is receiving a curative treatment: This is the correct statement. Palliative care can be integrated with curative treatment for clients with serious illnesses. It focuses on managing symptoms, providing emotional support, and improving the overall quality of life, regardless of whether the client is receiving treatment aimed at curing their illness.
Correct Answer is {"dropdown-group-1":"E","dropdown-group-2":"C"}
Explanation
Potassium Levels: The postoperative potassium level for the client is 3.0 mEq/L, which falls below the normal range of 3.5 to 5 mEq/L. Potassium is a critical electrolyte necessary for the proper functioning of cardiac muscles. It plays a pivotal role in maintaining the electrical conductivity of the heart. Hypokalemia, or low potassium levels, can disrupt this electrical conductivity, leading to abnormal heart rhythms or arrhythmias. Arrhythmias can manifest as palpitations, irregular heartbeats, or more severe cardiac events, which can be life-threatening if not addressed promptly.
Importance of Potassium in Cardiac Function: Potassium is essential for the repolarization phase of the cardiac action potential. It helps in the return of the cell to its resting state after each heartbeat. A deficiency in potassium disrupts this balance, increasing the risk of erratic heartbeats and arrhythmias. Low potassium can prolong the QT interval on an electrocardiogram (ECG), which is a marker for potential arrhythmic events.
Clinical Implications: For a postoperative client, maintaining electrolyte balance is crucial. Surgery and anesthesia can affect fluid and electrolyte levels, making it essential to monitor and correct any imbalances. The decrease in potassium levels from 3.5 mEq/L preoperatively to 3.0 mEq/L postoperatively highlights a trend that must be addressed to prevent complications such as arrhythmias.
Preventative Measures: To mitigate the risk of arrhythmias, the healthcare team should consider interventions to correct the hypokalemia. This may include administering potassium supplements orally or intravenously, depending on the severity and clinical context. Continuous cardiac monitoring may also be warranted to detect and manage any emerging arrhythmic events promptly.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.