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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
C. Suspending the infusion of packed RBCs is essential to prevent further administration of the blood product that may be causing the adverse reaction. Stopping the infusion allows for further assessment and appropriate management of the client's symptoms.
A. The client's symptoms of chills, lower back pain, and nausea suggest a potential transfusion reaction rather than respiratory compromise.
B. Collecting a urine sample may be indicated to assess for hemolysis or kidney injury, which can occur as a result of a transfusion reaction. However, this action can be deferred until after immediate interventions to manage the suspected reaction.
D. While checking the client's vital signs is important in assessing the severity of the reaction and the client's overall condition, it is not the first action to take when a transfusion reaction is suspected.
Correct Answer is A
Explanation
A. Strawberries aretypically associated with cross-reactivity with latex
B. Eggs are not commonly associated with cross-reactivity with latex.
C. Peanuts are not typically associated with cross-reactivity with latex. Peanut allergy involves specific proteins found in peanuts and is unrelated to latex allergy.
D Shellfish is not associated with cross-sensitivity with latex
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