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.
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Related Questions
Correct Answer is D
Explanation
A. Involves respiratory therapy for altered breathing from severe anxiety levels: This behavior demonstrates collaboration with other healthcare professionals but does not directly relate to a team approach for managing mobility issues.
B. Delegates assessment of lung sounds to nursing assistive personnel: Delegation of tasks such as assessing lung sounds is a nursing responsibility but does not involve the broader team approach necessary for comprehensive care.
C. Becomes solely responsible for modifying activities of daily living: Handling all aspects of a patient's care individually does not reflect a team approach, which involves collaborating with various specialists.
D. Consults physical therapy for strengthening exercises in the extremities: This behavior exemplifies a team approach by involving physical therapy specialists to address mobility issues. It reflects collaboration with other disciplines to provide comprehensive care.
Correct Answer is B
Explanation
A. Droplet: Incorrect. Droplet precautions are used for infections spread through respiratory droplets, such as influenza or meningitis, not for immunocompromised clients undergoing stem-cell transplants.
B. Protective: Correct. Protective precautions, also known as neutropenic precautions or reverse isolation, are necessary for clients who are immunocompromised, such as those who have had a stem-cell transplant. These precautions include using barrier protection to prevent infection due to the client's weakened immune system.
C. Contact: Incorrect. Contact precautions are used for infections spread by direct or indirect contact with contaminated surfaces or items, such as Clostridium difficile, not for immunocompromised patients.
D. Airborne: Incorrect. Airborne precautions are used for infections that spread through the air over long distances, such as tuberculosis or measles, and are not specifically needed for clients with compromised immunity post-transplant.
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