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 ["69"]

Explanation

Convert the weight from pounds to kilograms

190 lb * (1 kg / 2.2046 lb) = 86.183 kg (rounded to three decimal places)

The recommended dietary allowance (RDA) of protein:86.183 kg * 0.8 g/kg = 68.946 g/day

Rounding to the nearest whole number, the client should receive approximately 69 grams of protein daily.

A. Emesis of 250 mL B. Increased respiratory rate to 26/min C. Decreased anxiety D. Decreased urinary output

Correct Answer is C

Explanation

C. Morphine is a central nervous system depressant that can help decrease anxiety and relieve dyspnea in clients with acute heart failure. Therefore, a decrease in anxiety would indicate that the medication has been effective in achieving its intended outcome.
A. Emesis, or vomiting, is not an expected outcome of morphine administration in the context of acute heart failure.
B. While morphine can help alleviate dyspnea, an increased respiratory rate may indicate respiratory distress rather than effective symptom relief.
D. Morphine does not directly affect urinary output, and a decrease in urinary output may indicate other issues such as renal dysfunction or fluid overload.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["69"]

Explanation

A nurse is caring for a client who has acute heart failure and received morphine IV 30 min ago. Which of the following findings should the nurse identify as an indication that the medication was effective?

Correct Answer is C

Explanation

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