A nurse is reviewing a client's medical record. Which of the following findings should the nurse identify as a fall risk?
Inguinal hernia
Hyperlipidemia
Multiple sclerosis
Hyperthyroidism
The Correct Answer is C
A. Inguinal hernia: While an inguinal hernia can cause discomfort and potential complications, it is not typically considered a significant fall risk.
B. Hyperlipidemia: This condition affects cholesterol levels and is not directly related to an increased risk of falls.
C. Multiple sclerosis: MS can lead to muscle weakness, balance issues, and coordination problems, which significantly increase the risk of falls.
D. Hyperthyroidism: Although hyperthyroidism can cause symptoms like tremors and muscle weakness, it is less directly associated with fall risk compared to multiple sclerosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","E"]
Explanation
A. Placing a high risk for falls armband on the patient: An armband alerts all healthcare providers to the patient's fall risk, helping to ensure appropriate precautions are taken.
B. Checking on the patient once a shift: This is not sufficient; patients on fall precautions should be checked more frequently, such as every hour or according to the facility's protocol, to ensure their safety.
C. Keep the bed in the lowest position: Keeping the bed at its lowest position reduces the risk of injury from falls and helps ensure the patient can easily get in and out of bed.
D. Placing all four side rails in the "up" position: Using all four side rails is not recommended as it can increase the risk of entrapment and may not be effective in preventing falls. Side rails should be used appropriately and in accordance with safety protocols.
E. Maintain call light within reach of the patient: Ensuring the call light is within reach helps the patient call for assistance if needed, which can help prevent falls.
Correct Answer is ["A","D"]
Explanation
A. Provide educational material written at an eighth-grade reading level: Educational material should be understandable to the client, and an eighth-grade reading level is typically accessible for most individuals.
B. Turn on the television in the client's room: Turning on the television can be distracting and is not conducive to effective preoperative teaching.
C. Use technical language in the educational session: Technical language can be confusing for clients; plain language should be used to ensure understanding.
D. Start with the most important information: Prioritizing the most critical information ensures that the client understands essential aspects of their procedure, even if they cannot retain all details.
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