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 C
Explanation
A. Bronchial airway constriction: In the fight-or-flight response, bronchial airways actually dilate to increase airflow to the lungs, rather than constricting.
B. Hypoglycemia: The fight-or-flight response typically leads to increased blood glucose levels (hyperglycemia) to provide quick energy, not decreased levels.
C. Dilated pupils: During the fight-or-flight response, pupils dilate to improve vision and help the individual better detect threats. This is a classic manifestation of this stress response.
D. Decreased blood pressure: The fight-or-flight response generally increases blood pressure due to the release of adrenaline and other stress hormones that prepare the body for immediate action.
Correct Answer is A
Explanation
A. Financial difficulties: Correct. Financial difficulties are a psychological stressor as they impact mental and emotional well-being, contributing to stress.
B. Hypothermia: This is a physiological stressor, as it involves a physical condition affecting the body's health rather than psychological aspects.
C. Burn injury: This is also a physiological stressor resulting from physical harm rather than a psychological impact.
D. Wrist fracture: This is a physical stressor due to injury, not a psychological one, as it affects physical health rather than mental well-being.
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