A nurse is performing a fall risk assessment on a client. Which of the following findings indicates the client has an increased fall risk?

The client asks for help before ambulating.

The client has a history of urinary incontinence.

The client lives with their caregiver.

The client has bronchitis.

Answer and Explanation

The Correct Answer is B

B. Urinary incontinence can increase fall risk due to the need for frequent trips to the bathroom, which may increase the chances of tripping or falling, especially if the client rushes to the bathroom.
A. This indicates that the client is aware of their limitations and is proactive in seeking assistance, which may actually decrease their fall risk. It demonstrates awareness and caution.
C. While having a caregiver present can provide support and assistance, it doesn't necessarily indicate an increased fall risk. In fact, having a caregiver present may decrease the risk of falls by providing supervision and assistance as needed.
D. Bronchitis itself does not directly contribute to an increased fall risk.

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Correct Answer is C

Explanation

C. Uric acid is the end product of purine metabolism, and elevated levels of uric acid in the blood can predispose individuals to gout. In acute gout, there is often a marked increase in serum uric acid levels due to the release of uric acid from the breakdown of purines during the inflammatory process.
A. Chloride level is not directly associated with acute gout.
B. Creatinine kinase (CK) is an enzyme found in various tissues, including muscle tissue. Elevated CK levels are associated with muscle damage or injury, such as in cases of muscle trauma, myocardial infarction, or rhabdomyolysis.
D. Intrinsic factor is a glycoprotein produced by the parietal cells of the stomach that is necessary for the absorption of vitamin B12 in the small intestine.

A. Hypoglycemia B. Increased muscle mass C. Increased libido D. Hot flashes

Correct Answer is D

Explanation

D. Hot flashes are a common symptom following a bilateral orchiectomy due to the sudden decrease in testosterone levels. Hot flashes are characterized by sudden feelings of warmth, flushing, and sweating, often accompanied by a rapid heartbeat. These symptoms can be bothersome but are typically temporary and can be managed with lifestyle modifications and medications if necessary.
A. Hypoglycemia is not typically associated with a bilateral orchiectomy.
B. Testosterone, primarily produced by the testicles, plays a significant role in promoting muscle mass and strength. Removal of the testicles results in a significant decrease in testosterone production, which may lead to a gradual decline in muscle mass and strength over time.
C. Testosterone is a key hormone involved in regulating libido in both men and women. Removal of the testicles leads to a significant decrease in testosterone levels, which may result in a decrease in libido rather than an increase.

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A nurse is performing a fall risk assessment on a client. Which of the following findings indicates the client has an increased fall risk?

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Naxlex Comprehensive Predictor Exams

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